rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
11499,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,160,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to convey the funds, and a final accounting of those funds, within thirty (30) days after the death of the resident for two (2) of three (3) residents reviewed. Resident identifiers: #60 and #48. Facility census: 77. Findings include: a) Residents #60 and #48 The facility's resident funds accounts were reviewed at 8:30 a.m. on [DATE]. The balance of personal funds being held by the facility for two (2) of three (3) deceased residents reviewed had not been released within thirty (30) days after their deaths as required. Resident #60 passed away on [DATE]. Facility records show the balance of her personal account of $34.30 was not released until [DATE]. Resident #48 passed away on [DATE]. Facility records show the balance of her personal funds of $50.00 was not released until [DATE]. During an interview with the administrator (Employee #36) on [DATE] at 9:20 a.m., she confirmed these funds had not been conveyed within the required thirty (30) days. .",2014-01-01
11500,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,279,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to develop a care plan to include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident #21 was admitted for a planned short rehabilitation stay and remained in the facility after rehabilitation goals had been met. No care plan was implemented to address the resident's discharge needs. The resident also was known to be at risk for falls at the time of admission, and no care plan goals and interventions were developed to address the risk. The resident did incur additional falls. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 1. When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained ""multiple bilateral lower extremity fractures"". Review of the physician's determination of capacity for this resident divulged that, at the time of admission (10/26/10), the resident's attending physician determined she did not have the capacity to understand and make health care decisions. This determination was changed on 01/03/11, when it was determined at that time that she did possess the capacity to make those decisions. An entry in social service (SS) notes, dated 11/09/10, stated: ""D/C (discharge) plans are to return home."" Again on 11/24/10, a SS note stated: ""D/c plans remain to return home. No d/c date at this time."" On 01/17/11, a SS note stated: ""She plans to rehab & return home. MPOA (medical power of attorney) states resident will be LTC (long term care)."" One (1) of two (2) minimum data set assessment (MDS) coordinators (Employee #65), when questioned on 04/25/11 at approximately 11:00 a.m. about the resident's plan to return to her home, stated the resident was occasionally confused, and Employee #65 did not feel the resident could care for herself at home, manage her diabetes, etc. She further stated she did not think the resident's family was willing to help her at home. The resident's care plan, when reviewed on 04/25/11, contained no mention of discharge and/or discharge planning for this resident on this document, which was most recently updated on 04/11/11. When reviewed again on 04/26/11, the resident's care plan had been updated to reflect the uncertainty of the resident's plan to discharge home. The facility's social worker (Employee #27), when interviewed on 04/26/11, confirmed she had not initiated any care plan related to discharge for this resident until 04/26/11. This employee further confirmed the resident's ability to make medical decisions was questionable and that a review of her capacity status had been requested. Recent calls to the resident's family / MPOA had gone unreturned, according to this employee. -- 2. The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and ""yelled for help"" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for ""acute fractures"". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, ""I found resident sitting on floor between beds, she was yelling out, her alarm was on & working"". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start ""falling star"" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. .",2014-01-01
11501,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,280,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to revise the care plans of two (2) of forty (40) Stage II sample residents, when changes occurred in their health condition and/or treatment plan. Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. The resident's right leg was severely contracted, which caused the resident's right heel to push into the resident's buttocks. The staff had been applying heel protectors to the resident's heels to reduce pressure to these areas; the heel protectors were discontinued on 02/10/11, with no other intervention(s) added to address this unrelieved pressure against the right heel. The pressure on the heel from constant contact with buttocks resulted in a suspected deep tissue injury, which was identified on 04/03/11. At that time, the facility failed to identify this constant pressure as the cause of the pressure sore, and failed to revise her care plan to include measures to reduce / relieve this pressure until after the physical therapist was consulted on 04/19/11. Resident #41's care plan was not revised to reflect the application of a hand roll to address contractures of the resident's left hand. Facility census: 77. Findings include: a) Resident #28 Record review revealed Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. A review of Resident #28's minimum data set assessment (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 01/18/11, revealed the assessor identified, in Section G, that Resident #28 was totally dependent on staff for the performance of all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. In Section K, the assessor noted she did not have a significant weight loss either in the previous month or in the previous six (6) months. In Section M, the assessor noted she had no unhealed pressure sores and there were no pressure ulcers present on the prior MDS, although she was at risk for developing pressure sores in the future. Review of the Braden Scale assessment (for predicting pressure sore risk) dated 01/18/11, the resident scored ""13"", indicating she was at moderate risk for developing a pressure sore. A progress note recorded by the former MDS coordinator (Employee #63), dated 01/25/11, stated (quoted as typed): ""Quarterly care plan conference held today. ... Currently skin is intact , receives preventative skin treatments Q (every) shift. Float heels when in bed, air mattress, and heel protectors. resident has multiple contracture to extremities, refuses daily to get OOB (out of bed), will agree to get out of bed on 3-11 shift approximately 2 times a week. ..."" -- The resident's care plan, dated 09/16/08 to 08/04/10, identified the following problem statement (quoted as typed): ""Potential for impaired skin due to fragile skin, history of impaired skin, incontinence, impaired mobility, at risk for UTIS (urinary tract infection),unstageable area to left heel."" (A line was drawn through ""unstageable area to left heel"", followed by ""D/C (discontinued) 10/26/10"".) This problem statement was subsequently updated with handwritten entries as follows (quoted as written): - ""Will return to Rt (right) side /p (after) repositioning and use of repositioning aides."" (This entry was not dated or signed.) - ""4-29-10 Open area on left buttocks."" (This entry was subsequently marked as ""resolved"" on 06/01/10.) - ""8-4-10 blisters to left inner big toe and right little toe outer aspect."" - ""8/8/10 Open blister on rt. shoulder."" (This entry was subsequently marked through, with no date to indicate when this was discontinued.) - ""4/1/11 I am At risk for excoriation under my breast."" - ""4/22/11 SDTI (suspected deep tissue injury) (R) (right) heel."" (According to the NPUAP, a ""suspected deep tissue injury"" is defined as: ""Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue."") The goals associated with this problem statement included (quoted as typed and/or written): ""Resident will have intact skin through the next 90 days and will develop no UTIS. Area to left heel will reso;lve prior to next review. (This goal addressing the area to the resident's left heel was discontinued on 10/26/10, after the area was resolved.) ... 4/22/11 Will resolve SDTI (R) heel /s (without) complications through next review."" The interventions associated with the above problem statement with its subsequent revisions included (quoted as typed and/or written): ""Examine skin during bathing for signs / symptoms of irritation and/or breakdown. ... Assure proper positioning in/out of bed. Utilize pillows ect. as needed. Assess skin for S/S (signs / symptoms) of breakdowns, report to MD if so noted. ... OOB (out of bed) in geri-chair with cushion daily as tolerated. Turn and reposition as indicated. Heels up while in bed. skin prep to left heel twice daily for protection. Air mattress to bed to promote wound healing, ... Change and check for incontinence upon awakening, before and after meals, before bed and prn (as needed). ... Topical treatment to (R) heel as ordered."" Notations on the care plan revealed the use of ""(h)eel protectors while in bed"" was discontinued on 02/10/11. -- A separate care plan, dated 04/04/11, contained the following ""focus area"" (quoted as typed): ""I have SDTI to my (R) heel r/t (related to)[MEDICAL CONDITIONS] with multiple joint contractures, Hx (history of) ulcers, Immobility."" The goal associated with this focus was: ""The SDTI of my (R) heel will show signs of healing and remain free from complications through review date."" The interventions planned to achieve this goal were: ""I need to turn / reposition at least every 2 hours, more often as needed or requested. I need moisturizer applied daily and PRN to my skin. ... I require low air loss mattress to my bed. ... I require supplemental protein and nutritional supplements as ordered to promote wound healing. Administer treatments as ordered. ... Administer treatments as ordered and monitor for effectiveness (skin prep (R) heel as ordered). Assess / record/ monitor wound healing weekly. ... Monitor nutritional status. ... Monitor / document / report to MD PRN changes in skin status. ..."" The care plan did not recognize as the causative factor of the pressure sore the constant pressure from the right heel's contact with the resident's buttocks, and there were no interventions to reduce / relieve this pressure. -- An interview with the director of nursing (DON - Employee #63), on 04/25/11 at 11:00 a.m., revealed the facility was told by ""corporate"" to discontinue all heel protectors, because research showed the heel protector did not help with eliminating pressure from the heel. Instead, the facility was using other methods, such as floating the heels off of the bed and pillows. The DON further stated the intervention for floating Resident #28's heels could not be achieved related to her lower extremity contractures. -- An interview with the physical therapist, on 04/25/11 at 12:00 p.m., revealed the resident received an evaluation related to a pressure (black) area on the resident's right heel. According to the physical therapist, ""The right leg is very contracted and pushes against the resident's buttocks, causing pressure. We are treating the resident with pressure-relieving heel protectors which will prevent the heel from pushing against the resident's buttocks."" -- An observation of Resident #28, on 04/25/11 at 2:10 p.m., found her in bed in her room. A nurse (Employee #52) removed the resident's blankets, and the resident was observed to have a dime-sized area of eschar on her right foot. The resident had padded heel protectors on both feet. The resident's right leg was severely twisted up around her back, with the right heel fixed against her buttocks. The left leg was also observed as severely twisted and fixed in position. Padded heel protectors were on the resident's feet. Employee #52 stated, ""The resident is very difficult to move in bed. She refuses to get out of bed frequently and becomes very agitated when turned and repositioned."" She further stated, ""I just came on full time and before that I only worked part time. I really don't know much about the resident."" The resident's care plan directed staff to float the resident's heels off of the bed; however, this observation revealed the resident's lower extremities were so severely contracted that it was not possible to float her heels off of the bed. According to the NPUAP, the presence of eschar on the resident's right heel (as seen by the nurse surveyor on 04/25/11) is consistent with the NPUAP's definition of an ""unstageable"" pressure sore: ""Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. ... Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."" -- A review of the physical therapy evaluation dated 04/19/11 revealed, under the heading ""Reason for Referral"": ""Contracture mgmt. (management), Splint / Orthosis; Compromised skin integrity"". The long term goal for therapy was: ""Upon completion of therapy, pt (patient) will tolerate positioning wedge x 2 hrs to decrease pressure of feet on buttocks."" Under the heading ""Other Observations"" was: ""There is a nickel-sized area on her posterior right heel. It is covered with black eschar with an irregular border and red periphery. It is dry."" Under the heading ""Positioning"" was: ""Recommendations made for Equipment: Nursing recommending positioning device to relieve pressure from right heel due to a pressure area developing from heel being placed against buttocks."" Also under the heading was: ""Pt lies on either side with UEs (upper extremities) and LEs (lower extremities) contracted up into flexion. Her LEs are contracted to the extent that her feet are being pressed against her buttocks."" Review of the physical therapy weekly note dated 04/25/11 found, under the heading of ""Justification for Continued Treatment"": ""Pt was provided with padded heel protectors which demonstrated a good fit. The original positioning wedge appeared to be too large and the order was cancelled. Pt is tolerating gentle ROM (range of motion) / stretching, but occasionally will note discomfort. Continue with ROM as tolerated and monitor use of heel protectors. Also, a gel cushion has been ordered to apply to her chair for further pressure reduction."" -- An interview with the physical therapist, on 04/26/11 at 9:35 a.m., revealed a wedge was considered and was not ordered for the resident. The extra padded foot protectors were ordered and applied to keep the right heel from going against the resident's buttocks causing pressure. Some manipulations of the LE contractures allowed some extension to the contractures. The resident was unable to tolerate too much manipulation of the contracture. The physical therapist stated she was going to attempt to stretch as much as possible the contractures of the resident's lower extremities. -- A physician's progress note dated 04/15/11 stated: ""(Resident #28) developed in early April developed an area on her right heel. Initially it measured 1.2 x 1.6 centimeters areas is blackish brown in color. It is suspected to be a deep tissue injury. She has severe contractures, probably in the entire facility her contractures are worse than anyone that we have. I believe this is unavoidable because of the severe contractures. She has positioning therapy. She has been referred to physical therapy. Her pre-[MEDICATION NAME] level is still below normal at 17.3. We increased her 2CalHN (nutritional supplement) to 3 ounces q.i.d. (four-times-daily) with MedPass. She is on ProSource, Magic Cup, and she has an air mattress to try to aid prevention of skin breakdown and healing of the areas that do breakdown."" A physician progress notes [REDACTED]. integrity at that time. Similar physician progress notes [REDACTED]. -- A review of nursing notes, recorded immediately before and after the heel protectors were discontinued on 02/10/11, did not reveal evidence that staff recognized the resident's lower extremity contractures resulted in her right heel constantly pressing against her buttocks. The following entries were noted with respect to the resident's heels: - On 02/06/11 at 2:00 p.m. - ""... Skin warm, dry, & intact. (Symbol for 'no') new area noted to skin. ..."" - On 02/20/11 at 2:25 p.m. - ""... Skin warm & dry, intact. Skin prep cont (continued) to heels. ..."" - On 03/06/11 at 10:15 a.m. - ""... Skin warm, dry & intact, skin prep to (B) (both) heels. ..."" - On 03/13/11 at 3:00 p.m. - ""... Remains on low air low mattress /c (with) (+) (positive) functioning & no bottoming out due to high risk for breakdown. Skin currently intact /c no pressure areas noted. ..."" - On 03/20/11 (7-3 shift) - ""... Skin assessment reveals (symbol for 'no') new skin issues."" - On 03/27/11 (7-3 shift) - ""... skin intact, (symbol for 'no') skin issues ..."" - On 04/03/11 at 2:00 p.m. - ""Resident's skin assessment completed. Right heel /c SDTI 1cm x 2 cm observed. Skin prep orders received and applied. ..."" - On 04/04/011 at 10:30 a.m. - ""(R) (right) heel /c SDTI ..."" -- Review of the resident's physician orders [REDACTED]. - On 04/03/11 at 2:00 p.m. - ""Skin prep to right heel every shift for two weeks then re-eval. Suspected deep tissue injury."" - On 04/04/11 at 1430 (2:30 p.m.) - ""Order clarification: Skin prep to both heels every shift. SDTI / [MEDICATION NAME] treatment."" - On 04/05/11 at 5:00 p.m. - [MEDICATION NAME] level d/t (due to) Stage I wound."" - On 04/06/11 at 1515 (3:15 p.m.) - ""... Order clarification - [MEDICATION NAME] level of 4-6-11 for SDTI."" No orders were received to address the underlying cause of the pressure sore until 04/19/11, when the following orders were received: - On 04/19/11 at 11:55 a.m. - ""PT eval & treat."" - On 04/19/11 at 11:55 a.m. - ""PT services 3 x 1 wk x 4 wks for LE stretching / ROM & positioning devices to decrease pressure & improve LE positioning while in bed."" -- b) Resident #41 Observation of Resident #41 revealed multiple joint contractures, with a Posey hand roll in use for contractures of the left hand. Review of the resident's current recapitulation of physician's orders [REDACTED]."" Review of Resident #41's care plan revealed the presence of left hand contractures, but the care plan was not revised to address the use of the Posey hand roll. During interview with the director of nursing on 04/21/11 at 11:30 p.m., she agreed the resident's care plan did not mention using a Posey roll or other splinting device for the contractures of the left hand, noting that in the past this resident refused them, but in recent times she had not been resistive to its application. .",2014-01-01
11502,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,323,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, observation, and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to care plan and/or implement measures to promote safety related to falls. Resident #21 was admitted to the facility on [DATE], after having been hospitalized for [REDACTED]. Interventions to promote safety related to falls were not addressed in her care plan until two (2) months after her admission, when the physician ordered a bed alarm on 12/28/10. Additional interventions (to include placing the resident's bed in a low position) were not added to the resident's care plan until the resident sustained [REDACTED]. When observed on 04/26/11, Resident #21 was observed to be asleep in her bed, but her bed was not in the low position as care planned. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained ""multiple bilateral lower extremity fractures"". The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and ""yelled for help"" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for ""acute fractures"". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, ""I found resident sitting on floor between beds, she was yelling out, her alarm was on & working"". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start ""falling star"" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. The resident was observed to be in bed asleep at 10:30 a.m. on 04/26/11. The bed was not in the low position. This observation was confirmed by a second surveyor at that time.",2014-01-01
11503,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,285,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to assure a reassessment was completed for a resident who was approved for nursing facility placement for less than three (3) months and remained in residence after six (6) months. Resident identifier: Resident #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. Documentation found on page 5 of 6 of form PAS2000 for this resident disclosed, in Section #38 titled ""Physician Recommendation"", a nursing facility stay of less than three (3) months had been determined necessary for this resident. The resident had been at the facility for nearly six (6) months at that time. The facility's social worker (Employee #27), when interviewed on 04/25/11 at 1:15 p.m. following a review of the resident's record, confirmed the resident had not undergone reassessment, and the form PAS2000 had not been resubmitted following the initially approved three (3) month period. .",2014-01-01
11504,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2010-09-23,311,E,,,5AUJ11,". Based on record review and staff interview, the facility failed to provide daily restorative nursing services for residents designated to receives those services. Record review revealed specific written plans to meet specific goals for residents in the restorative nursing program. However, restorative aides were, at times, pulled to work the floor in the capacity of a nursing assistant due to staffing shortages, leaving the restorative nursing services undone. During interviews with certified nursing assistants (CNAs) conducted on 09/22/10, seven (7) of eight (8) CNAs interviewed reported they do not follow the restorative nursing plan; rather, they perform range of motion to restorative residents the same as they do to all dependent residents during the performance of activities of daily living. Resident identifiers: #10, #12, #49, #56, #57, #59, #61, #65, #70, #73, #77 #81, and #82. Facility census: 101. Findings include: a) Resident #10 Review of the Restorative Nursing Program (RNP) Flow Sheet, found in the restorative book for September 2010, revealed he was to ""perform active assist range of motion (ROM), bilat (bilateral) upper ext (extremities) all joints 3 sets of 20 (twenty) reps (repetitions) daily."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - b) Resident #12 Review of the RNP Flow Sheet for September 2010 revealed Resident #12 was to receive ""Active ROM (range of motion) ex (exercise) 2 sets 15 reps (repetitions) in seated position (heel / toe raises, seated marches, knee extension / flexion, hip abduction / adduction) daily"". Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/7, 9/8, 9/9, 9/10, 9/12, 9/13/, 9/14, 9/15, 9/16). Resident #12 was also to ""Ambulate /c (with) rolling walker - contact guard of 1 assist to daily tolerance / distance."" Restorative staff documented having provided this service on only six (6) of the first 20 (twenty) days in September (9/7, 9/8, 9/9, 9/10, 9/15/ 9/16). - c) Resident #49 Review of the RNP Flow Sheet for September 2010 revealed Resident #49 was to receive ""active assist ROM 3 sets 15 reps each (seated marches, knee ext while seated, hip abduction / adduction)"" and ""Ambulate /c rolling walker - min (minimum) assist of 1 (symbol for increase) to 50 ft or more as tolerated."" Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September, with four (4) refusals. Dates documented for both plans were 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16. - d) Resident #56 Review of the RNP Flow Sheet for September 2010 revealed Resident #56 was to receive: ""Bilat (bilateral) lower ext (extremity) - active ROM 2 sets x 15 reps ... (seated marches, hip abduction / adduction, knee extension / flexion, heel / toe raises - dorsal / plantar flexion)."" Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to: ""Ambulate /c rolling walker (10 - 30 ft) - verbal cue to keep walker @ correct distance in front of her."" Restorative staff documented having provided this service on only three (3) of the first twenty (20) days of September, with three (3) refusals (9/4, 9/7, 9/8, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to have: ""Active Assist ROM (R) (right) upper ext (extremity) - 3 sets 15 reps... Active ROM (L) (left) upper ext - 3 sets 15 reps."" Restorative staff documented having provided this service on only seven (7) of the first 20 (twenty) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - e) Resident #57 Review of the RNP Flow Sheet for September 2010 revealed Resident #57 was to receive: ""Active ROM - 3 sets 15 reps... passive ROM LUE (left upper extremity) and (L) hand - 3 sets 15 reps... wash & dry (L) hand - remove splint q (every) day - report any skin issues to nurse."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - f) Resident #59 Review of the RNP Flow Sheet for September 2010 revealed Resident #59 was to maintain bilateral upper extremity strength and ""use 7 lb therapy bar during course of ADL (activity of daily living) - 3 sets - 20 reps or to tolerance."" This treatment was to have begun on 09/21/10. During an interview with Employee #54 on 09/22/10 at 11:30 a.m., she said it was not begun on 09/21/10, as staff did not know where the therapy bar was kept in the physical therapy department. - g) Resident #61 Review of the RNP Flow Sheet for September 2010 revealed Resident #61 was to: ""Ambulate up to 300 ft /c rolling walker - contact guard assist (may continue after resting) for (symbol for increased) ambulation if desired."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to have: ""Bilat (bilateral) lower ext (extremity) 2 sets 15 reps AROM (active range of motion)... 2 lb ankle weight (seated marches, knee extension / flexion, hip abduction / adduction, dorsal / plantar circles... heel / toe raises."" Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September on (9/4, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - h) Resident #65 Review of the RNP Flow Sheet for September 2010 revealed Resident #65 was to: ""Ambulate 400 ft + (plus) /c supv (supervision) - no assistive device."" Restorative staff documented having provided this service on eleven (11) of the first twenty (20) days of September (9/1, 9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). Also, she was to have: ""AROM bilat lower ext - cues may be necessary (heel / toe raises, knee extension / flexion, hip abduction / adduction) 2 sets - 15 reps."" Restorative staff documented having provided this service on only eleven (11) of the first twenty (20) days of September (9/1, 9/3, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 916). She was also to receive: ""Active ROM bilateral upper ext 3 sets - 20 reps... verbal cues /c ADL's (activities of daily living) - dressing / grooming / toileting."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). - i) Resident #70 Review of the RNP Flow Sheet for September 2010 revealed Resident #70 was to have: ""Left upper ext all planes active ROM 3 sets - 20 reps."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with one (1) refusal. - j) Resident #73 Review of the RNP Flow Sheet for September 2010 revealed Resident #73 was to: ""Ambulate /c rolling walker - CGA (contact guard assist) 300+ ft ... Active ROM BLE ex (bilateral lower extremity exercise) - heel / toe raises, seated marches, knee extension, hip abduction / adduction... Active ROM ex (exercise) - bilat upper ext all planes 3 sets - 30 reps."" Restorative staff documented having provided these service, which included two (2) days when the resident was out of the facility, on only nine (9) of the first twenty (20) days of September (9/1, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - k) Resident #77 Review of the RNP Flow Sheet for September 2010 revealed Resident #77 was to have"" ""Active ROM ex (L) upper ext 3 sets - 15 reps use 2 lb wgt (weight) if possible... Active assist ROM (R) upper ext 3 sets - 15 reps... Bilat lower ext active ROM 3 sets - 15 reps (ankle pumps, knee extension, hip flexion, seated marches, hip abduction / adduction."" Restorative staff documented having provided these service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - l) Resident #81 Review of the RNP Flow Sheet for September 2010 revealed Resident #81 was to: ""Ambulate /c rolling walker 150 ft min (minimum) contact guard assist... verbal cues to (symbol for increase) step length / stay inside walker."" Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with four (4) refusals. - m) Resident #82 Review of the RNP Flow Sheet for September 2010 revealed Resident #82 was to have: ""Active ROM - bilat lower ext - 3 sets 15 reps (seated marches, hip abduction / adduction, seated knee ext (extension)."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to: ""Ambulate /c rolling walker - contact guard assist of one to tolerance."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days in September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - n) During an interview with a restorative aide (Employee #58) on 09/20/10 at 5:45 p.m., she stated that restorative services were provided for each resident seven (7) days per week. She said there was one (1) restorative aide who worked from 10:00 a.m. to 6:00 p.m., and there were two (2) restorative aides who worked the 7:00 a.m. to 3:00 p.m. (7-3) shift. She said two (2) restorative aides were pulled to work the floor today, leaving the other restorative aide to obtain weights on thirty (30) residents and then work 1:1 with another resident. For this reason, the restorative aides did not perform restorative nursing services today to all residents who to receive services - other than restorative dining in the dining room for five (5) residents; a nurse would be at the restorative table for the evening meal. She said she did not perform range of motion exercises or assist with ambulating any restorative residents in the hall today. - o) During an interview with a nurse (Employee #43) on 09/21/10 at 2:00 p.m., regarding all the ""blanks"" in the Restorative Book where nothing was documented to show restorative services were done on those days, she said a new program went into effect the beginning of September whereby copies of the RNP Flow Sheets for residents and their specific treatments are placed in the NA's (nursing assistant's) ADL (Activities of Daily Living) book for NAs to sign on days they provide restorative nursing services. - p) During an interview with another nurse (Employee #101) on 09/21/10 at 2:10 p.m., she said the nursing assistants do the restorative care on the 7-3 shift if the restorative aides get pulled to work the floor. - q) During interviews on 09/21/10 at 2:20 p.m. with nursing assistants who provided care today or yesterday to the following residents (Employees #31, #94, and #59), the aides were asked what restorative nursing services they provided and answers were as follows: - For Resident #31 - ""walked him to the bathroom and to the chair"", ""got range of motion to the upper and lower extremities today for a total of 10 minutes - restorative did it."" - For Resident #63 - ""was taken to the bathroom and transferred back and forth to the commode"" - For Resident #6 - ""transferred from the bed to the chair, moved arms and legs about 10 minutes"" - For Resident #56 - ""took her to the bathroom about ten times"" - For Resident #23 - ""helped during bathing"" - For Resident #10 - ""walked to the bathroom twice"" - For Resident #17 - ""worked arms and legs when changed"" - For Resident #82 - ""walked her to the bathroom and back"" - For Resident #49 - ""walked to the bathroom twice"" - For Resident #70 - ""walked to the bathroom to the hallway and to the chair"" - For Resident #81 - ""walked him to the bathroom"" - For Resident #66 - ""walked to the bathroom"" - For Resident #92 - ""had range of motion to the upper extremities today for 10 minutes - restorative did it."" - r) During an interview with Employee #43 on 09/21/10 at 3:15 p.m., she said the process for the CNAs to provide restorative care when the restorative aides were not available just started the first of September. She stated that the CNAs, nurses, and physical therapy have all met with inservices given, and all the CNAs should know how to do restorative nursing services, but perhaps not all know how to do it correctly yet. When asked, she said she believed the restorative aide positions were here to stay, but she was certain. However, they want to empower the CNAs to be able to do restorative nursing care as part of their daily duties. - s) During an interview with the director of nursing (DON) on 09/21/10 at approximately 5:30 p.m. regarding what nursing assistants said they were providing to restorative residents on days the restorative aides were absent or pulled to the floor to work as CNAs, she said it was probably just the ""verbiage"" they were unfamiliar, with as they have all received inservice education on restorative care. - t) During interviews with eight (8) nursing assistants (Employees #31, #27, #54, #55, #59, #94, #112, and #108) on 09/22/10 from 10:00 a.m. to 11:45 a.m. seven (7) of the eight (8) replied, when asked, that they do ADLs with residents who are in the restorative program and do range of motion to their joints during the process of performing routine care, just as they do for all dependent residents. They were in agreement that, when they sign on the Restorative Nursing Flow Sheet, they are signifying that range of motion was completed during their shift plus getting them up in a chair and/or walking them to the toilet if they are able. They were in agreement that the restorative staff perform lengthy ambulation per the restorative plan, although they (the CNAs) will walk a resident in the hall if he/she asks; and it is the restorative staff that does specific exercises (such as seated marches, etc., and exercises with repetitions and sets), not the CNAs. One (1) of the eight (8) CNAs said she does the exercises and repetitions according to the Restorative Nursing Plan, but she said she was not sure what hip abduction / adduction entails. Also, she was unable to describe what PROM and AROM entails. - u) During an interview with the staff development nurse (Employee #104) on 09/22/10 at 12:15 p.m., she reported the facility conducted a CNA class that ended in July with twelve (12) graduates, and five (5) of them are currently working at the facility. Also, the current CNA class graduates on 09/23/10, with six (6) students in that class and they test on 10/09/10. She said the next class begins on 09/29/10 with ten (10) students. She spoke of her desire for the facility to be able to hire and retain more CNAs. - v) Prior to exit for the day on 09/22/10 at approximately 4:00 p.m., the DON was informed of the continued concern regarding whether residents in the restorative nursing program were getting services as specified in the restorative nursing program flow sheet on days the restorative aides were absent or were pulled to work the floor as CNAs (instead of restorative aides). No further evidence was produced prior to exit on 09/23/10.",2014-01-01
11505,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,152,D,,,E5O711,"Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, ""When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate."" The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. .",2014-01-01
11506,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,225,E,,,E5O711,"Based on review of personnel records and other facility documents and staff interview, the facility failed to assure comprehensive screening was completed for three (3) of five (5) newly hired employees. Additionally, the facility failed to report an allegation of abuse involving one (1) resident to the State survey and certification agency and other officials in accordance with State Law. These deficient practices had the potential of affecting more than an isolated number of residents currently residing in the facility. Employee identifiers: #7, #14, and #76. Resident identifier: #2. Facility census: 29. Findings include: a) Employees #7, #14, and #76 1. Review of personnel records, on the afternoon of 05/29/0,9 found the facility did not obtain references from two (2) known previous employers prior to hiring Employee #7. 2. Further review found the facility did not obtain a criminal background check for the state of Ohio, when this state was listed as a previous residence of Employee #14. 3. It was also found the facility failed to access the Nurse Aide Abuse Registry to assure Employee #76 did not have findings of abuse or neglect registered with this state agency. Employee #32, who was assisting with review of the personnel records, was unable to provide evidence to show the required pre-employment screening for Employees #7, #14, and #76 was obtained by the facility. b) Resident #2 Review of facility records found, on 05/04/09, the daughter of Resident #2 sent an e-mail to the social services director alleging Employee #3 was ""... smacking Mom's behind for wanting up at night to use the potty chair ... The woman may be teasing with Mom, but Mom is taking it as a punishment. Mom should not have to receive this treatment."" Further review could find no evidence this allegation of abuse was reported to the State survey and certification agency or adult protective services in accordance with State law. An interview with Employee #32, on the afternoon of 05/29/09, confirmed this allegation had not been reported as required. .",2014-01-01
11507,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,329,E,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and pharmacist recommendation, the facility failed to assure the drug regimens of three (3) of ten (10) residents remained free from unnecessary drugs, used in excessive dose, for an excessive duration, and/or without indications for use. Resident identifiers: #1, #14, and #10. Facility census: 29. Findings include: a) Resident #1 1. Review of the medical record found Resident #1 was currently receiving [MEDICATION NAME] 50 mg twice-a-day (BID) and [MEDICATION NAME] 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge the pharmacist's recommendation. 2. Further review found the resident received [MEDICATION NAME] 1 mg at bedtime. A pharmacy recommendation, dated 01/20/08 (more than fifteen (15) months earlier) notified the physician that a gradual dose reduction needed to be attempted every six (6) months. The physician did not acknowledge the pharmacist's recommendation, and the resident remained on [MEDICATION NAME] 1 mg at bedtime. b) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses administered [MEDICATION NAME] 500 mg for a total of eight (8) days beginning at 2:00 p.m. on 04/13/09, and continued [MEDICATION NAME] mg for seven (7) days after receiving the laboratory report. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. .",2014-01-01
11508,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,428,D,,,E5O711,"Based on medical record review and review of a pharmacy report of irregularities for two (2) of ten (10) sampled residents, the facility failed to assure the pharmacist's recommendation for a gradual dose reduction of Ativan was acted upon by the physician. Resident identifiers: #1 and #14. Facility census: 29. Findings include: a) Resident #1 Review of the medical record found Resident #1 was currently receiving Lyrica 50 mg twice-a-day (BID) and Neurontin 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge or act upon the pharmacist's recommendation. b) Resident #14 Review of the medical record found a pharmacy's consult to the physician dated 04/22/09. The pharmacist notified the physician the resident was ordered MS (morphine sulfate) 30 mg BID on 04/06/09, in addition to a current order for Oxycodone 10/650 every six (6) hours as needed (PRN) for pain. The pharmacist noted the order for Oxycodone did not contain parameters for nursing as to when the PRN Oxycodone should be administered. The physician failed to acknowledge or act upon the pharmacy recommendation. .",2014-01-01
11509,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,502,D,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure laboratory services were obtained for one (1) of ten (10) sampled residents. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found the resident was administered antibiotics for treatment of [REDACTED]. The treating physician ordered a repeat urinalysis with urine culture on 04/12/09. Review of the medical record found no evidence the laboratory test was obtained. An interview with a member of the nursing staff (Employee #27), on 05/28/09 at 9:50 a.m., confirmed the facility had not obtained the ordered test. .",2014-01-01
11510,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,505,D,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the physician was promptly notified of laboratory findings for two (2) of ten (10) sampled residents. Resident identifiers: #14 and #10. Facility census: 29. Findings include: a) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days on 04/10/09. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses continued to administer both [MEDICATION NAME] 500 mg [MEDICATION NAME] mg after receiving the laboratory culture which indicated no bacteria growth after forty-eight (48) hours. The medical record contained no evidence the facility notified the physician of the laboratory results. An interview with a member of nursing staff (Employee #27), on the morning of 05/29/09, confirmed the facility could provide no evidence the physician was notified. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. The facility could provide no evidence the physician was notified in a timely manner of the laboratory results to assure Resident #10 received the appropriate antibiotic to treat her UTI in a timely manner. .",2014-01-01
11511,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,309,D,,,E5O711,"Based on medical record review and staff interview, the facility failed to assure appropriate follow-up nursing assessment was provided to one (1) of ten (10) sampled residents. Nursing staff documented Resident #10 experienced bright red bleeding from the perineal area with no evidence of continued monitoring or assessment. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found a 04/20/09 nursing note which documented the resident was having a small amount of bright red bleeding from the perineal area during her bed bath at 10:30 a.m. The nursing note documented that, upon assessment, the bleeding appeared to be coming from the urinary meatus. The medical record contained no further information concerning the bleeding from the resident's perineal area. The next nursing note was not written until the weekly note on 04/24/09. An interview with a member of the nursing staff, on the morning of 05/29/09, could provide no evidence the resident received further assessment or monitoring of the area. .",2014-01-01
11512,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,312,E,,,XJ0U11,". Based on record review, resident interview, and staff interview, the facility failed to assure residents were provided personal hygiene as needed and as planned by the facility. Each resident had scheduled shower days twice weekly. Residents were randomly selected for review from each of four (4) halls and equally from 7-3 and 3-11 shifts. Two (2) of four (4) residents residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. These findings excluded any showers offered but refused by residents and marked on the ADL (activities of daily living) sheets as refused. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care- planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided. .",2014-01-01
11513,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,353,E,,,XJ0U11,". Based on record review, resident interview, and staff interview, the facility failed to deploy sufficient direct care staff across all shifts and units to ensure residents received personal hygiene as needed and as planned by the facility. Record review revealed two (2) of four (4) residents (#43 and #66) residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. When interviewed, Resident #43 reported she wanted her showers but sometimes did not get them because staff was too busy. In confidential interviews, nursing assistants on both the 7:00 a.m. to 3:00 p.m. (7-3) shift and the 3:00 p.m. to 11:00 p.m. (3-11) shift reported they have not been able to complete showers as scheduled in the past month or obtain the assistance of a second staff member for turning and repositioning residents who were assessed as requiring the assistance of two (2) for bed mobility due to a lack of availability of staff. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care-planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided.",2014-01-01
11514,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,281,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of ""Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses"" (revised 06/17/09), and medical record review, the facility failed to provide goods and services in accordance with professional standards of quality, by assigning a licensed practical nurse (LPN) to complete in-depth skin assessments (including making a determination regarding the staging of pressure ulcers), an act outside her scope of practice. This practice affected one (1) of ten (10) sampled residents (#145) with the potential to affect all residents with pressure sores. The facility also failed to assure that physician orders [REDACTED]. This practice affected one (1) of ten (10) sampled residents (#152) with the potential to affect any other resident with similar physician orders. Resident identifiers: #145 and #152. Facility census: 142. Findings include: a) Resident #145 1. An interview was conducted, on 01/06/11 at 3:40 p.m., with registered nurse (RN - Employee #187) related to the care and services provided to promote healing to former Resident #145. During this interview, Employee #187 requested the assistance of the wound nurse, Employee #127 (who was an LPN). While discussing the interventions that had been put into place for Resident #145, Employee #127 described her contribution to the assessment of pressure ulcers. The LPN reported, at 3:55 p.m. on 01/06/11, that she was responsible for all the pressure ulcers of residents on the A, B, and C units of the facility. She stated she measured the wound beds; identified / described the presence of any tunneling, drainage, and colors; and staged the wounds. When asked if she had received specialized training in the assessment and staging of wounds, Employee #127 stated she did not have any additional credentials such as a wound care specialist. - 2. The administrator was asked, on the afternoon of 01/07/11, for evidence that the LPN (Employee #127) had received training or education in assessing and staging pressure ulcers. The administrator was unable to provide any evidence that this LPN had received formal training beyond entry level. - 3. Review of ""Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses"" (revised 06/17/09), which was published jointly by the State's licensing boards for RNs and LPNs, found the following on page 6: ""Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care. The Boards receive many questions about the LPN's role in the assessment component of the nursing process. While the law does not specifically address the issue of the LPN's role in the assessment process, the rule clearly places the responsibility for the analysis of the data on the RN..."" Review of page 12 found a section entitled ""Guidelines for Delegation of Nursing Acts To the Licensed Practical Nurse"", which contained the following language: ""1. Delegation of acts beyond those taught in the basic educational program for the LPN should be based on a conscious decision of the registered nurse. - Practice beyond entry level for the LPN should not be automatic nor should it be based solely on length of experience. 2. Practice beyond entry level must be competency based. - Competency based practice is defined by structured educational activities which include assessment of learning and demonstration of skills. 3. Records of educational activities designed to enhance entry level knowledge, skill and ability must be maintained and available to the RN making the decision. - The employer and the employee must maintain records which include an outline of the educational content and an evaluation of achievement of educational objectives and demonstrated skills..."" - 4. An interview with the RN assessment coordinator (Employee #48), who was responsible for the completion of the minimum data set (MDS) assessment, was conducted on 01/07/11 at 5:15 p.m. via telephone. She agreed that she was responsible for completing the pressure ulcer assessment section of each resident's MDS. When asked how she determined the stage of pressure ulcers, she stated she retrieved that information from the facility's weekly wound tool. When asked if she personally assessed resident wounds prior to completing the assessment portion of the MDS and staging the wounds, she stated she did not assess the wounds in order to complete this section of the MDS. - 5. A follow-up interview with Employee #127 was conducted via speaker phone on 01/07/11 at 6:15 p.m., in the presence of the administrator and the director of nursing (DON). Employee #127 verified she completes the weekly wound tool and stages the wounds. When asked if she received assistance in doing this from the RN, she stated, ""Very rarely do I have to ask about a wound."" -- b) Resident #152 Review of Resident #152's medical record found that, on 12/21/10 at 4:15 a.m., the physician gave the following orders: ""Hold pain medications, [MEDICATION NAME], ... [MEDICATION NAME] until BP (blood pressure) comes up. Monitor BP Q (every) 30 minutes."" 1. With respect to holding these medications in the presence of low blood pressure, the order did not contain clear and specific instructions to the licensed nurses to indicate when the resident's blood pressure was high enough to prompt the nurses to restart the medications. An interview with the DON, on the afternoon of 01/05/11, confirmed this order should have been clarified by the nursing staff. 2. With respect to the on-going monitoring of the resident's blood pressure, the order did not contain parameters to indicate at what point the licensed nurses were to discontinue monitoring the resident's blood pressure at a frequency of every thirty (30) minutes. Review of the medical record found the licensed nursing staff followed the physician's orders [REDACTED]. .",2014-01-01
11515,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,441,D,,,XJ0U13,". Based on random observation and staff interview, the facility failed to implement an infection control program which effectively helped prevent the potential spread of disease and infection in the facility. A staff member was observed to rinse a bed pan soiled with urine in the sink in a resident's bathroom. This same staff member also obtained drinking water from other sinks to fill residents' water pitchers. This was true for one (1) of ten (10) sampled resident. Resident identifier #105. Facility census: 142. Findings include: a) Resident #105 At approximately 11:30 a.m. on 01/04/11, Employee #33 was observed to assist Resident #105 off a bedpan. The NA (nursing assistant) emptied the urine from the bedpan into the toilet located in the resident's room. The NA then turned on the water in the resident's sink and rinsed the bedpan. This nursing assistant was previously observed filling Resident ' s water pitchers at others sinks. The NA, who was interviewed immediately following the observation, was asked what she thought about rinsing bedpans from the same sink that drinking water was obtained. The NA stated it was ""gross"" because the ""urine splashes up"". .",2014-01-01
11516,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,501,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's medical director failed to assume responsibility for the coordination of facility-wide medical care. There was no evidence of ongoing collaboration by the medical director with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct continuing non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care. Additionally, the medical director failed to coordinate medical care by not assuring Resident #143 received timely physician visits, and failed to assume the care of Resident #152 when nursing staff contacted him for medication for the resident, instructing staff to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. These practices affected two (2) of ten (10) sample residents during the current survey and had the potential to result in more than minimal harm to more than an isolated number of facility residents. Resident identifiers: #152 and #143. Facility census: 142. Findings include: a) The facility has had continued non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care (F309) during the last three (3) survey events at the facility, beginning with a survey event that concluded on 09/01/10, resulting in findings of deficiencies in quality of care at a level of harm. There was no evidence of ongoing collaboration with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct this continuing non-compliance. (See also citation at F309.) - b) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, ""This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file."" The medical director had not assured this attending physician saw this resident in a timely manner. (See also citation at F387.) - c) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to, in part, to the medical director's failure to render assistance in obtaining the necessary medication. (See also citations at F309 and F425.) .",2014-01-01
11517,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,387,D,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of ten (10) sample residents received a physician visit in the facility at least once every thirty (30) days for the first ninety (90) days after admission. This resident, who resided in the facility from [DATE] until 12/17/10, had no face-to-face visits with his attending physician. Resident #143. Facility census: 142. Findings include: a) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, ""This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file."" .",2014-01-01
11518,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,225,D,,,9G3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, review of facility documents, and staff interview, the facility failed to ensure two (2) of two (2) allegations of neglect / abuse were reported immediately to the State survey and certification agency and other officials in accordance with State law, and failed to thoroughly investigate the allegations of neglect / abuse. It was further determined that, due to the failure of the facility to report and investigate allegations appropriately, the facility failed to take appropriate corrective actions. The facility failed to immediately report one (1) allegation of neglect, when a staff member failed to assure Resident #81's bed was placed in the low position with landing strips (utilized to pad the floor) placed beside the resident's bed prior to leaving the resident unattended, in accordance with the resident's physician orders. The resident fell from her bed and sustained a [MEDICAL CONDITION] which required surgical repair. The facility did not report this allegation until three (3) days after the incident. The facility failed to report, investigate, or take appropriate corrective actions when Residents #117 and #52 made complaints to facility staff concerning Employee #5 on 08/26/10, and requested that she no longer provide care for them. Resident identifiers: #81, #117, and #52. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 was found on the floor of her room. The resident's bed was left in a high position with no ordered landing strips placed on the floor beside her bed. The resident was subsequently hospitalized with a [MEDICAL CONDITION] which required surgical repair. Further review of facility documents found the graduate nursing assistant (Employee #136), who had been assigned to provide care for the resident on the day of the fall, claimed to be unaware that the resident was to have landing strips beside her bed. Review of the medical record found a current physician's orders [REDACTED]. The facility's records showed this allegation of neglect was not reported to State agencies until 08/25/10, three (3) days after the incident. An interview with the licensed social worker (LSW - Employee #73), on 09/08/10 at 4:45 p.m., confirmed the facility did not report the allegation of neglect immediately to adult protective services and the State survey and certification agency as required. - b) Residents #117 and #52 During random interviews conducted with alert and oriented residents on 09/09/10, Resident #117 stated, at 8:45 a.m., that approximately two (2) weeks ago, she woke up at 2:00 a.m. and asked a nursing assistant (Employee #5) to assist her in getting up. The resident stated Employee #5 refused to assist her and told her that she had to stay in the bed. The resident stated she asked the nursing assistant from the other hall (Employee #89) to help her get out of bed, and this aide assisted her. The resident further stated that, after being assisted up and going into the hallway, Employee #5 pointed her finger at her and told her it would be a long time before she could go back to bed. This allegation was reported to the director of nursing (DON - Employee #10) at 9:10 a.m. on 09/09/10. She denied having prior knowledge of this incident. Review of the resident council minutes for 08/26/10 found a communication from a member of the activities department (Employee #84) to the DON at 4:15 p.m., which stated, ""(Resident #117 and Resident #52) no longer want (Employee #5) to take care of them, they each have different issues regarding her care and I ask that u (you) please speak with them both."" An interview with Employee #84, at 12:50 p.m. on 09/10/10, confirmed the residents were complaining about Employee #5. She stated this was a nursing issue and she had reported it to both the DON and the unit manager. The DON, when asked at 10:10 a.m. on 09/09/10 about the 4:14 p.m. communication on 08/26/10, stated that, when she received, it she assigned it to her unit manager, and the issue has now been reported. Review of the 09/09/10 reported allegation of neglect related to Employee #5 found the facility both reported the allegation and completed the five-day follow-up on 09/09/10. The investigation merely consisted of the unit manager's late entry nursing note dated 09/07/10. The document contained no attempts to determine the date the incident happened, no attempts to obtain statements from the residents or staff members who were either involved in the incident or were potential witnessed the incident. Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 06/30/10, assessed Resident #117 as being independent in cognitive skills for daily decision making with no deficits with long or short term memory, no indicators of [MEDICAL CONDITION], no mood problems, no behavioral problems, and being able to understand and make herself understood. The facility assessed the resident as requiring the extensive physical assistance of one (1) staff member with transfers. Review of the resident's current care plan, provided by the facility on 09/09/10, found under the problem of activities of daily living (ADL): ""Resident is dependent with transfers with slideboard."" The facility did not report or investigate potential allegations of abuse / neglect when informed of Residents #117 and #52's concerns on 08/26/10. Additionally, the nursing assistant (Employee #5) who was the subject of resident complaints continued to be assigned to care for Residents #117 and #52 when no attempts had been made that ensure it was safe to do so. .",2014-01-01
11519,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,224,G,,,9G3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to ensure that goods and services were provided to prevent physical harm to one (1) of eight (8) sampled residents. Facility staff failed to assure that physician-ordered landing strips (utilized to pad / cushion the floor) were placed beside Resident #81's bed and failed to assure her bed was in a low position when left unattended on 08/22/10. Resident #81 fell from the bed and sustained a [MEDICAL CONDITION] requiring surgical repair. The graduate nursing assistant (Employee #136) responsible for the resident's care on 08/22/10 denied having knowledge of the requirement to place landing strips beside the resident's bed. The facility failed to put into place a system to orient new employees and temporary agency staff to the planned / ordered interventions to be provided to each resident. Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 fell from her bed to the floor. Facility staff documented the resident's bed was in a high to knee-high position with no physician-ordered landing strips present to cushion the floor beside the resident's bed. The resident sustained [REDACTED]. Review of the medical record found an active physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/10, found the resident was assessed as being severely cognitively impaired with impaired long and short term memory, and she required the extensive physical assistance of one (1) staff member for bed mobility, transfers, dressing eating, toilet use, and personal hygiene. The assessor also noted resident had sustained a fall in the thirty (30) days prior to the ARD. - Further review of facility information, concerning Resident #81's fall from bed on 08/22/10, found Employee #136 stated she had no knowledge that the resident was to have landing strips placed beside her bed. Review of the one-on-one education, conducted by the facility on 08/30/10, found the nurse informed the staff member: ""...there are Kardex (sic) on every station. Please look at your resident's Kardex at beginning of shift to ensure you are aware of interventions in place to prevent falls and to give appropriate care."" There was a lack of evidence to reflect the facility put procedures in place to inform other new staff and temporary agency staff of the care information located in the Kardex prior to providing care to assigned residents. - An interview was conducted with a nursing assistant employed by an outside temporary staffing agency (Employee #140) at 7:40 a.m. on 09/09/10. She was asked to show this surveyor where she would locate care instructions to assure that residents received appropriate care and services, such as, landing strips, bed height, splints, etc. Employee #140 walked behind the nursing station and retrieved the activity of daily living (ADL) book. When the documents were reviewed in the ADL book, it was noted that it merely contained a record of the residents' bowel movements, intake, bathing, etc. The book contained no instructions to staff concerning landing strips, bed height, splints, or other necessary care and services to be provided. When asked what a Kardex was, the aide stated that she did not know. A subsequent interview with the charge nurse on the unit (Employee #6) revealed she had not oriented the agency nurse aide as to where to locate the Kardex to access care information for residents. .",2014-01-01
11520,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,514,D,,,9G3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to maintain the medical record of one (1) of eight (8) sampled residents in accordance with accepted professional standards and practices. Resident #81 sustained a fall resulting in a [MEDICAL CONDITION], but her medical record contained no progress note entries addressing the fall or the resident's subsequent hospitalization . Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found Resident #81 sustained a fall from her bed on 08/22/10 and suffered a [MEDICAL CONDITION] requiring surgical repair. Review of the medical record found no nursing progress note or other documentation of the resident's fall and subsequent transfer to the hospital. An interview with the director of nursing (DON - Employee #10), on 09/10/10 at 4:00 p.m., confirmed the medical record did not contain progress notes or any other documentation of the resident's fall and subsequent transfer to the hospital on [DATE].",2014-01-01
11521,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,242,D,,,9G3Y11,". Based on review of resident council minutes and staff interview, the facility failed to assure one (1) random resident with a sample of eight (8) residents was afforded the right to choose bathing schedules consistent with aspects of his life in the facility that were significant to him. Resident identifier: #25. Facility census: 118. Findings include: a) Resident #25 Review of resident council minutes for 06/23/10 found Resident #25 requested that he be provided showers three (3) times a week. The response from the facility stated, ""Not staffed for 3 showers per week."" Under discussion of old business for the 07/26/10 resident council meeting, the minutes documented, ""We are not staffed to give residents 3 showers a week."" An interview with the administrator, on 09/09/10 at 9:10 a.m., revealed the wishes of the resident should have been honored. .",2014-01-01
11522,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,241,D,,,9G3Y11,". Based on observation, the facility failed to assure one (1) of eight sampled residents (Resident #96) was provided care in a manner that maintained her dignity while being transported through the hallway to the shower. Resident identifier: #96. Facility census: 118. Finding include: a) Resident #96 Random observations of the facility, on 09/08/10 at 4:10 p.m., found a staff member transporting Resident #96 through the hallway on a shower chair. The resident was seated on a commode-seat type shower chair. The staff member had placed a sheet around the top of the resident but failed to assure the resident's bottom was covered. The resident's unclothed buttocks were visible beneath the chair as the staff member pushed her down the hallway. This practice was brought to the attention of the unit manager (Employee #53), who obtained a sheet from the clean linen cart in the hallway and assured the resident was adequately covered. .",2014-01-01
11523,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,364,E,,,9G3Y11,". Based on observation, resident interview, and staff interview, the facility failed to assure the evening meal served on 09/08/10 was prepared in a manner that assured the food was palatable and attractive. This deficient practice affected more than an isolated number of residents receiving an oral diet. Facility census: 118. Findings include: a) Random observation of the evening meal, on 09/08/10, noted residents were served two (2) mounds of a grey-white gelatinous substance containing green flecks. It was noted that none of the residents eating in their rooms consumed the substance. When asked how the evening meal tasted, a resident (who wished to remain anonymous) described the taste as ""Yucky"". Another resident stated that it smelled like dog food. An interview with the dietary manager (Employee #16) was conducted at 6:25 p.m. on 09/08/10. When inquiry was made as to what the two (2) mounds of green-flecked substance served to residents were, she stated, ""Turkey Tetrazzini."" She stated the broccoli was overcooked due to the cook having to take her test and not getting back in time. She agreed the meal did not smell or look appetizing. .",2014-01-01
11524,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,314,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was ""large and foul-smelling"" and the odor was ""overpowering""; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. The nursing admission evaluation, dated 07/14/10, identified the resident was admitted with a Stage II pressure sore on the coccyx area measuring 5 cm x 4 cm x 0.2 cm, a Stage I pressure sore on the right hip measuring 2 cm x 2 cm, and a Stage I pressure sore on the left heel measuring 5 cm x 6 cm. On 07/14/10, the physician ordered the following treatment to the Stage III pressure sore on the coccyx: ""Stage III coccyx: Cleanse q3d (every three days) /c (with NSS (normal sterile saline). Apply [MEDICATION NAME] Aq. Cover /c [MEDICATION NAME] dsg (dressing)."" On 07/15/10, the order was changed to: ""Cleanse area /c NSS. Apply [MEDICATION NAME] (white). Cover /c [MEDICATION NAME]. Change dressing Q3D (every three days) & PRN (as needed)."" A review of the resident's comprehensive care plan, with an initiated date of 07/15/10, revealed the following problem statement: ""Stage I on right hip, left heel and stage (sic) III on coccyx related to recent hospitalization secondary to refusing to eat, drink, diabetes, mobility, contractures, impaired mobility (sic), incontinence."" The goal associated with this problem statement was: ""Skin will heal within the limits of the disease process."" Interventions intended to assist the resident in achieving this goal included: "" ... Evaluate and record wound status per facility guidelines until healed. ... Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify family / responsible party of skin condition. ..."" - 4. A late entry in the skin progress notes, dated 07/15/10 (for 07/14/10), stated, ""Res (resident) admitted on [DATE] /c (with) diagnosis (sic) of UTI, [MEDICAL CONDITION], dementia,[MEDICAL CONDITIONS], TIA ([MEDICAL CONDITION]), contractures of upper & lower extremities. She had a Braden (scale) of 9 on admit (sic) very high risk for skin breakdown. Also not eating / drinking at hospital. She was admitted /c a Stage I on Right hip 2 x 2 red area, not open, PUSH = 6. Stage III on coccyx - 5 x 4 x 0.2 20% slough /c 80% granulation, no odor, no drainage, no swelling, no c/o (complaints of) pain /c tx (treatment). PUSH score = 12, also has a Stage I on left heel 5 x 6 , PUSH score = 10. Tx order. ... Enc (encourage) to eat & drink. ..."" A skin progress note, dated 07/21/10, stated, ""Wound rounds completed. DCD (director of care delivery) & wound nurse on rounds. (R) (right) hip 1 x 0.2 PUSH = 3 Stage I - coccyx 0.8 x 3.0 x 0.2 D (depth) PUSH = 8 Stage III - (LE) (left) heel 4 x 6 PUSH = 9 Stage I. Coccyx - 75% slough / 25% granulation, 0 (no) odor, 0 drainage, 0 swelling, 0 s/s (signs / symptoms) infection - tolerated tx well. ..."" A skin progress note, dated 07/29/10, stated, ""Wound rounds completed. Late entry (for 07/28/10). DCD ' s, DON (director of nursing), wound nurse, dietary, therapy present. (R) hip - 0.8 x 0.5 Stage I PUSH = 2, (L) heel - 3.0 x 5.0 Stage I PUSH = 9, coccyx - 2.8 x 0.7 x 0.3 Stage II PUSH = 7, 10% slough 90% granulation, 0 odor, 0 drainage, 0 s/s inf (infection) 0 s/s pain. ... Cont /c ordered tx."" A skin progress note, dated 08/04/10, stated, ""Wound rounds completed. DON, DCD ' s, wound nurse & therapy present. (R) hip 1.4 x 1.0 Stage = I PUSH = 5. (L) HEEL 2.0 x 3.0 Stage = I PUSH = 7. Coccyx 7.0 x 7.0 x 0.8 unstageable PUSH = 14 50% necrotic tissue, 25% slough, 25% granulation. 0 odor, 0 drainage, 0 s/s inf. 0 s/s pain. ... Cont /c ordered tx."" From 07/28/10 to 08/04/10, the pressure sore on Resident #115's coccyx increased in size and was no longer able to be visualized for staging due to the presence of necrotic tissue, although the wound care nurse documented there was no odor, drainage, or signs / symptoms of infection. The Stage I pressure sores or the resident's right hip and left heel did not open or change during this time. - 5. A review of the nursing notes, from 07/15/10 until 08/07/10, did not contain any assessment of the resident's pressure sores or documentation to reflect identification of any odor or other signs / symptoms of infection in the pressure sore on the resident's coccyx. - 6. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 7. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..."" A hospital follow-up note, dated 08/26/10, stated: "" This patient had a large decubit that was debrided and getting wound VAC (vacuum-assisted closure) treatment. The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 8. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" - 9. An interview with the wound care nurse, a registered nurse (RN - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when the pressure sore on Resident #115's coccyx was assessed to have increased in size on 08/04/10 and was not able to be visualized for staging due to the presence of necrotic tissue, she did not call the physician. She further stated she was new to the position and relied on some of the other nursing staff to tell her what she needed to do concerning the pressure sores. She also stated that, now, if a resident's pressure sore changed as Resident #115's did, she would call the physician immediately and schedule the resident with the wound clinic. She stated she works during the week and, after she leaves the facility each day, the floor nurses are responsible for the treatments. The floor nurses are also responsible for the treatments on the weekends. - 10. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker went into the emergency room . She stated, ""The odor from the pressure sore was overpowering. I could not stand the smell. The emergency room nurses took pictures of the pressure sore on the resident's coccyx. It was large and foul smelling."" She further stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" - 11. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 12. The resident was admitted to the nursing home on 07/14/10, with a Stage III pressure sore on the coccyx. On 08/04/10, the pressure sore became larger in size and was no longer able to be visualized for staging due to the presence of necrotic tissue; neither the resident's MPOA nor the attending physician was notified of the deterioration in the status of this pressure sore. (See citation at F157.) On 08/07/10, the resident's MPOA asked that the resident be sent to the hospital. Upon arriving at the hospital, the pressure sore was found to be overwhelmingly malodorous and severely infected; however, the nursing notes in the resident's medical record at the nursing facility failed to identify the presence of any odor or signs / symptoms of infection prior to her transfer to the hospital. During the resident's second hospital stay, she required treatment with intravenous antibiotics related to the infected wound, and the wound subsequently received surgical debridement. .",2014-01-01
11525,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,327,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... "" According to a Transfer Summary Report hemodynamically stable"". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. Upon admission, the physician ordered a ""no added salt"", pureed diet with ""level II fluids"" (honey-thick liquids). According to the resident's weights and vitals summary, her weight on admission (07/14/10) was 130.0# and her height was 63 inches. The diet order was changed to mechanical soft with pureed meats and nectar-thick liquids on 07/20/10. - 3. A nutrition risk assessment, completed by a registered dietitian (RD) on 07/21/10, identified Resident #115 as being at HIGH RISK (score of 8 or higher), with a total score of 16. The RD calculated the resident's total fluid needs as 1737 cc/day. The resident's risk factors included an average intake of 33% at meals during a 7-day observation period, dementia, an [MEDICATION NAME] level of 2.7 (residents with [MEDICATION NAME] of less than 3.0 are at high risk), and one (1) Stage III pressure sore on the coccyx (with Stage I pressure sores also noted on the right hip and left heel). The RD recommended the addition of ""Med Pass Supplement 2.0 60 ml 4 x day"" on 07/21/10 to provide additional calories and protein for wound healing. On 07/27/10, the physician ordered: ""Dietary consult - res(ident) not eating. ..."" On 07/28/10, the RD noted, ""Consult for res refusing to eat and wt (arrow pointing down) (sic) Res current wt 9-25-10 90.6 (pounds) /s (without) boots verified by re-wt. Boots weighed = 1# each. Res wt 7-23-10 98.2# wt 7-22-10 99.4# wt 7-18-10 127.4#. 130# 7-14-10. (Arrow pointing down) 39.4# / 30% / since adm (admission). Wt quest (questioned) on admit. Res has been refusing to eat per Nsg (nursing). Res current diet NAS mech soft, pureed meats & nectar liquids. Res avg (meal intake) 13% x 7 days (arrow pointing down) from 33% last review 7/21/10. Res currently receiving Med Pass 2.0 60ml 4 x day to supplement diet. Staff stated res consumed ice cream well 7-27-10 Rec (recommend) to add magic cup 1 x day at afternoon snack to provide 300cal/9g protein. Will contact POA to updated likes & dislikes. Will continue to encourage meal intakes."" On 07/29/10, the RD noted, ""Update (sic) res has started to consume meals better per Nsg (nursing). Nsg stated res will consume bite if presented /c (with) ice cream in between bites. ... D/T (due to) res intakes at meals are improving recommend to add Benical to lunch tray to help meet res needs. No further recommendations at this time. ..."" While the RD was addressing the resident's weight loss and nutritional needs on a periodic basis, there was no mention of whether the resident was meeting her daily fluid needs. - 4. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the need to monitor the resident's hydration status, in view of the fact that her final [DIAGNOSES REDACTED]. - 5. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 6. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration. A review of all problems, goals, and interventions identified on the 14-page care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. Nursing notes indicated, beginning on day of admission, that resident would refuse to eat by refusing to open her mouth. The resident would eat for the MPOA on visit to the facility. A nursing note, dated 07/25/10 at 10:30 a.m., revealed, ""... Staff able to get 2 bites of brfast (breakfast) & 60 ml of fluid into resident this am (morning)."" On 07/27/10 at 10:00 a.m., a nursing note revealed, ""... Res conts (continues) to ref (refuse) to eat / drink ... Res conts to allow food / liq (liquid) to run out of mouth."" - 8. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 9. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 10. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" She further stated, ""I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection."" - 11. There was no evidence to reflect the facility had routinely assessed / monitor Resident #115's hydration status / fluid balance for signs / symptoms of dehydration with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. - 12. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 13. In an interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., she stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" .",2014-01-01
11526,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,309,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide care and services necessary to attain or maintain the highest practical level of physical well-being for one (1) of twelve (12) sampled residents. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, severe dehydration, and an infected pressure sore. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in her hydration status, quantity and quality of her urinary output, and/or presence of signs / symptoms of UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: ""Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations."" The goals associated with this problem statement were: ""Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction"" and ""No acute infection"". The interventions intended to assist the resident in achieving these goals were: ""Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care."" - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found no evidence of periodic assessment or monitoring of the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI. The nursing notes did, however, note the resident was refusing to open her mouth and was not eating and/or drinking. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. Patient was also given IV antibiotic, [MEDICATION NAME] 1 gram daily and [MEDICATION NAME] 250 mg IV daily. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute on [MEDICAL CONDITION]. ..."" - 9. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" She further stated, ""I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection."" - 10. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 11. There was no evidence to reflect the facility conducted periodic assessment or monitoring of the resident's hydration status, of the quality or quantity of the resident's urinary output, or for the presence of signs / symptoms of a UTI with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. .",2014-01-01
11527,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,157,D,,,GVP311,". Based on record review and staff interview, the facility failed, for one (1) of twelve (12) sampled residents, to notify the resident's medical power of attorney representative (MPOA) and attending physician when the status of the resident's pressure sore significantly declined. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 A review of the facility's weekly skin report for Resident #115, dated 08/04/10, found: ""The coccyx measurement is not able to be staged."" The pressure sore was described as measuring 7 cm x 7 cm x less than 0.8 cm with eschar. This was a significant change from the previous week when, on 07/28/10, the pressure sore on the resident's coccyx measured 2.8 cm x 0.7 cm x 0.3 cm and no eschar was present. A review of nursing notes, on 08/04/10, did not find evidence to reflect either the physician or the resident's MPOA was notified of this significant decline in status of the resident's pressure sore. An interview with the wound care nurse (a registered nurse - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when on 08/04/10 the resident's pressure sore was assessed to be larger and was not able to be staged due to the eschar, she did not call the physician or notify the MPOA. .",2014-01-01
11528,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,225,E,,,GVP311,". Based on record review and staff interviews, the facility did not ensure that four (4) of eight (8) resident concern forms reviewed, containing allegations of resident abuse / neglect involving nursing assistants, were reported to the State nurse aide registry. Resident identifiers: #115, #116, #117, and #20. Facility census: 114. Findings include: a) A review of the facility's complaint file revealed four (4) resident concern forms containing allegations of resident abuse / neglect which involved nursing assistants. These allegations of abuse / neglect were reported to the facility by family members and residents as follows: 1. A concern form, dated 07/20/10, stated the medical power of attorney representative (MPOA) of Resident #115 reported finding the resident lying wet with food on her clothes. 2. A concern form, dated 08/21/10, stated Resident #116 ""stated she wanted to use BSC (bedside commode) but was told by 11-7 (night shift staff) that she needed to use the bedpan - 'that it's our protocol'. When she used the bedpan, the bed got wet. Res (resident) states only the top sheet was changed & the fitted sheet was still wet. When she told the CNA (certified nursing assistant) the bottom sheet was still wet, res says CNA said 'It's not wet unless you peed again' then (symbol for 'checked') the sheet & told res is was dry. Later res says she was cold & asked for a blanket. States CNA took her temp (97.1) & was told she 'didn't need a blanket.' Res was upset enough to tell (name of nurse) that she was ready to sign out AMA (against medical advice) the next morning. ..."" 3. A concern form, dated 08/21/10, stated, ""... Res (Resident #117) said 'I'm not one to complain' then hesitated. When asked what the problem was, he said 'You know. Night shift.' I asked what happened. Res stated 'When I had my light on, they came in & said 'What do you want now.' Res inferred it was said in a (sic) unpleasant tone of voice. Res then said CNA turned off the light & left the room."" 4. A concern form, dated 07/15/10, stated, ""Resident (#20) upset this AM (morning) stated that NS (night shift) ref (refused) to assist to BSC. Resident stated that NS staff told her that they could not get her OOB (out of bed) to BSC D/T (due to) only 3 staff & she requires 2 ppl (people) to do. Resident state (sic) this is a dignity issue. 'Why can't they not stand & pivot?'"" - An interview with the assistant director of nursing (ADON - Employee #23), on 09/02/10 at 3:05 p.m., revealed she was in charge of reviewing the complaints and reporting allegations to the appropriate State agency(ies). She further stated the four (4) complaints with the allegations of abuse / neglect were investigated by her and were not submitted to the State agency. She stated she talked with the nursing assistants involved but did not submit the allegations to the State nurse aide registry. - In an interview on 09/02/10 at 4:30 p.m., Resident #20, who was alert and oriented with the capacity to understand and make her own health care decision, stated she had asked an aide to assist her to the bedside commode and the aide refused. The resident knew who the aide was, but would not tell the surveyor. The resident stated she had told the facility's investigating nurse the name of the aide. She further stated, ""This was a dignity issue."" .",2014-01-01
11529,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,155,D,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only ""comfort measures"", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select ""comfort measures"", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 5. Review of the nursing notes revealed an entry, dated 07/18/10 at 3:50 p.m., stating, ""... (Resident) Resting in bed until lunch. POA (power of attorney) in. Upset that her instructions (sic) not followed. Wants resident up prior to BRK (breakfast). ... This nurse was under the impression that this resident was to stay in bed & that she was comfort measures. Many CNA's (certified nursing assistants) also were of similar belief. ..."" In a progress note dated 08/01/10, the physician stated, ""Pt's (patient's) PO (oral) intake poor but pt's POST form does not allow any tube feeding. ... Plan - continue comfort measures. ..."" - 6. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 7. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m. revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" - 8. The facility failed to ensure all staff was aware of and honored this resident's advance directives. .",2014-01-01
11530,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,279,D,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to develop a comprehensive care plan for one (1) of twelve (12) sampled residents describing the services to address all medical and nursing needs that were known to the facility. Resident #115 was admitted to the facility following a hospital stay during which she was treated for [REDACTED]. No care plan was developed to address the need for ensuring the resident maintained adequate hydration status / fluid balance and did not acquire a repeat UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found multiple entries reporting the resident was refusing to open her mouth and was not eating and/or drinking. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: ""Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations."" The goals associated with this problem statement were: ""Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction"" and ""No acute infection"". The interventions intended to assist the resident in achieving these goals were: ""Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care."" A review of all problems, goals, and interventions identified on the 14-page comprehensive care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" .",2014-01-01
11531,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-11-03,280,D,,,GVP312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and/or revise the comprehensive care plan when the health care status and care needs changed for three (3) of fifteen (15) sampled residents. Resident identifiers: #4, #7, and #11. Facility census: 113. Findings include: a) Resident #4 A review of the medical record revealed Resident #4 was an [AGE] year old female admitted on [DATE] with multiple diagnoses. She was re-hospitalized shortly after admission and readmitted to the facility on [DATE]. Her attending physician ordered ""Comfort Measures Only"" on 10/15/10, due to a decline in her health care status and the recent [DIAGNOSES REDACTED]. The nursing notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""just wanted to go to sleep"". A review of the resident's care plan revealed there were no goals set and no nursing interventions to address the ""End of Life Care"" needs of this resident. During an interview with one (1) of the assistant director of nurses (ADON - Employee #3) at 2:40 p.m. on 11/02/10, she acknowledged these needs should have been addressed when the ""Comfort Measures Only"" order was written on 10/15/10. At 3:20 p.m. on 11/02/10, Employee #3 also confirmed there was no care plan revision addressing the resident's ""End of Life Care"" needs. -- b) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was recently hospitalized and readmitted on [DATE]. On 10/22/10, a suprapubic catheter was placed to aid in the healing of a pressure ulcer on the coccyx, a skin tear of the rectum, and the chronic UTIs. A review of the clinical record, on 11/02/10, failed to find evidence of a revision of the comprehensive care plan to include goals and nursing interventions for the care of the suprapubic catheter. There was also no interim plan of care established. The nursing notes on 10/27/10 documented there was urine seepage into the resident's adult incontinence brief, indicating that additional care was needed by direct care staff. During an interview with the director of nursing (DON - Employee #2) and both ADONs (Employees #3 and #4) at 12:40 p.m. on 11/02/10, they acknowledged, after reviewing the resident's current care plan, that a revision to address the presence of the suprapubic catheter had not been done. At 1:00 p.m., the Employee #3 returned, after checking the care plan books and the computer, and verified that the care needs associated with the presence of Resident #7's suprapubic catheter were not addressed in either the comprehensive or interim care plan. -- c) Resident #11 A review of the medical record revealed Resident #11 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Her current comprehensive care plan, which was initiated on 08/03/10 and revised on 08/12/10, stated she was ""At risk for injury r/t (related to) fall due to impaired balance / poor coordination, [MEDICAL CONDITION]."". The goals associated with this potential problem were to ""minimize"" falls and/or injuries. The nursing interventions to meet these goals were: ""Assess for fall risk and reassess as needed; Bed in low position""; and Provide assist to transfer and ambulate as needed."" The nursing notes and an incident report related the resident sustained [REDACTED]. She sustained a laceration and was transported to the emergency room for sutures and a brain scan. The resident assessment protocol (RAP), completed by the nurse (Employee #4) on 10/11/10 stated a care plan was to be ""initiated / revised"" to address this. However, review of her care plan found no evidence of any revisions to prevent future falls, and there were no interventions addressing the safe use of the wheelchair. During an interview with the DON and both ADONs at 12:40 p.m. on 11/02/10, Employee #4 verified she had stated in the RAP that the resident's care plan would be reviewed / revised. At 1:30 p.m., the Employee #3 presented a copy of the RAP and acknowledged there had been no changes to the care plan after the resident's fall with injury. .",2014-01-01
11532,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-11-03,514,D,,,GVP312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure an accurate and complete medical record by failing to transcribe a physician's phone order into the correct locations on the medical record which resulted in confusion during the investigation of a potential medication error in the treatment of [REDACTED]. Resident identifier: #7. Facility census: 113. Findings include: a) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female who received [MEDICATION NAME] daily for control of a [MEDICAL CONDITION] disorder. A recent hospitalization resulted in new medication orders when she was readmitted to the facility. When readmitted on [DATE], the physician ordered: ""[MEDICATION NAME] (125 mg/5 ml) 7.5 ml TID (3 times daily) PO (by mouth) and [MEDICATION NAME] 5 ml Q HS (at bedtime) PO."" On 09/30/10, these orders were changed. All previous [MEDICATION NAME] orders were discontinued, and the physician ordered: ""[MEDICATION NAME] 7.5 ml @ 8:00 a.m.; 5 ml @ 12:00 p.m.; and 7.5 ml @ 4:00 p.m. PO."" On 10/21/10, the laboratory results showed a drop in the resident's serum [MEDICATION NAME] level, and when the physician was notified, documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] (125 mg/5 ml) 5ml Q HS PO."" There was no evidence in the physician's orders [REDACTED]. During an interview with the nurse (Employee #7) at 2:30 p.m. on 11/02/10, she stated, after reviewing the record, that she was the nurse who had reported the laboratory values to the physician's office and received the new order, which she had placed on the MAR, but she had failed to transcribe the order onto the physician's orders [REDACTED].",2014-01-01
11533,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2010-09-28,441,D,,,QQ4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: ""1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10."" Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - ""F/C patent to leg ..."" - On 07/27/10 - ""F/C patent to leg drainage bag. Orange urine noted ..."" - On 07/28/10 - ""F/C patent to drainage on leg bag. Some leakage noticed but good flow ..."" - On 07/30/10 - ""Cath was removed yesterday R/T (related to) burning and leaking ..."" During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/03/10, found no growth of MRSA at that time, although the culture was positive for Morganella morganii. On 08/26/10, the physician ordered, ""Discontinue Isolation."" - c) In an interview at approximately 3:00 p.m. on 09/28/10, Employee #2 (the registered nurse who has responsibility for the infection control program at the facility) identified that Resident #27 should not have resided in the room with Resident #90 after the indwelling urinary catheter was inserted into Resident #27 (as this created an open portal for entry by infectious organisms). Employee #2 presented a copy of a reference she used in her facility for MRSA. The reference material came from the following Internet site: . The reference material stated the following: ""Contact precautions must be used when a resident is colonized or infected with MRSA in any site other than the nares .... Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. ""Contact precautions consist of the following components: ""Contact precautions must be used when a resident is colonized or infected with MRSA IN ANY SITE OTHER THAN THE NARES ... Contact precautions consist of the following components. ""1. Room placement and Activities ""- A resident who is colonized or infected with MRSA at any body site other than the nares should be placed according to the following scheme: ""-- Most Desirable: A private room or cohorting with another resident who is colonized / infected with MRSA. ""-- Less Desirable: A room with another resident who has intact skin and no 'tubes' (invasive feeding tubes, tracheotomy tubes, any type of intravascular line, any type of indwelling urinary drainage tube, or any other tube or device that breaks the skin or enters into a normal body orifice).""",2014-01-01
11534,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,157,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, an interview with the family nurse practitioner, and medical record review, the facility failed to notify the health care decision maker for one (1) of six (6) sampled residents after the resident's oral medications were discontinued. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the physician's orders [REDACTED]. Documentation on the physician's orders [REDACTED].#59 of the changes in the resident's medications. This was confirmed by an interview with the FNP and the resident's attending physician at 9:00 a.m. on 09/09/10. The FNP said the medications were discontinued after the FNP had a discussion with the MPOA. She said she told the MPOA she would evaluate the resident's ability to swallow and then decide if she was going to discontinue the oral medications. She said she went into the resident's room, sat the resident up in the bed, and gave the resident a drink of water. This was documented on a progress note written by the FNP on 08/19/10. The 08/19/10 progress note stated: ""Chief complaint: F/U (follow-up) CXR (chest x-ray) (8/18/10) and F/U lethargy (8/18). CXR impression with New findings of subtotal collapse of right lung, possibly due to mucous plug or occult [MEDICATION NAME] lesion. ""Neuro: Unchanged: lethargic, but will open eyes and speak when stimulated. ""Neuro Addendum: Assessed swallowing, sat her up in bed at 90 degrees, tilted head forward, she drank 2 oz, but then coughed. ""Impression: Stable chronic Problems: End stage lung CA. Terminal condition. Prognosis Poor. Suspect dysphagia and high risk for aspiration. ""Plan: No change in Care Today: Called (Resident #59's MPOA) on her cell phone and updated (Resident #59's) condition. Report CXR results, VS and physical exam findings. Requested [MEDICATION NAME] give for possible 'pneumonia' Advised that [MEDICATION NAME] will probably not change outcome but will order it. (Resident #59's MPOA) stated, 'I just want her comfortable and not afraid...'"" The FNP said the resident was unable to swallow, so she discontinued all of the oral medications for the resident, except for two (2) which were inadvertently missed while reviewing the medications. These were [MEDICATION NAME] and [MEDICATION NAME]. The physician's orders [REDACTED]. She also did not tell the facility's nursing staff to contact the MPOA. During an interview on 09/08/10 at 1:45 p.m., Employee #58 (a licensed practical nurse - LPN), who was present at the nursing station on 08/19/10 when the FNP spoke with Resident #59's MPOA, said she thought the FNP was going to discontinue the resident's oral medications. She said the FNP was going to evaluate the resident. Employee #58 thought the FNP told the MPOA that she was going to discontinue the medications. During an interview on 09/09/10 at 9:40 a.m., the matter of Resident #59's MPOA was not notified after the resident's oral medications were discontinued on 08/19/10 was discussed the director of nursing (DON). The DON said the first time she became aware that the MPOA had not been notified of the discontinuation of oral medications was on 08/22/10, when the attending physician did not want to restart the medications. .",2014-01-01
11535,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,281,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and a review of the facility's policy regarding medication administration, the facility failed to ensure that medications were given as ordered by the physician. Resident #59 did not receive Tylenol every six (6) hours for three (3) days as ordered by the attending physician. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 ""Administering Medication"" policy (Revised 09/05 and 07/01/06) found Item #12 stated, ""Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, ""Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times."" .",2014-01-01
11536,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,514,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of facility policy, the facility failed to maintain clinical records for each resident that were complete and accurately documented in accordance with facility policy, for one (1) of six (6) sampled residents. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 ""Administering Medication"" policy (Revised 09/05 and 07/01/06) found Item #12 stated, ""Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, ""Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times.""",2014-01-01
11537,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-09-16,204,D,,,WF8P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to provide sufficient preparation at discharge of one (1) of six (6) sampled residents to ensure an orderly transfer from the facility, by failing to safeguard and return timely to the resident and/or responsible party important personal documents left in the facility's possession on admission which could not be produced at the time of the resident's discharge. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #94 During an interview at 3:15 p.m. on 09/13/10, Resident #96's responsible party reported she had not yet received the resident's Medicare benefits card, social security card, or her driver's license, which she had given to staff at the time of the resident's admission to the facility on [DATE]. Resident #96 was discharged from the facility on 08/20/10. The responsible party stated these identification cards were necessary for obtaining health care services for the resident. Review of the resident's closed record revealed a copy of the resident's Medicare benefits card, confirming it had been presented to the facility. There was no mention in the record of the location of the original card. During an interview with the social worker (Employee #8) at 10:40 a.m. on 09/16/10, she acknowledged the cards had not been returned and, in fact, could not be located. She stated she had met with the resident's daughter shortly before her mother's discharge and returned jewelry that had been held for the resident in the facility's safe. At that time, the daughter asked her about the cards. Employee #8 had no knowledge of the cards and had assured the daughter she would locate them and have them returned. She stated this duty had been given to the admissions clerk, who reported she had them in her possession and volunteered to return them. A week ago, the social worker had been contacted again by the resident's daughter, who had again requested the cards. When asked, the admissions clerk told Employee #8 that she had attempted to return them, and the daughter would not come to her door. The social worker stated that, on 09/10/10, she had prepared a letter to be sent to the daughter by certified mail on 09/13/10, and she produced the letter requesting the daughter to contact the facility and arrange for the return of the cards. This letter was not sent because, when the social worker arrived at the facility on Monday 09/13/10, she discovered the admissions clerk had quit on Friday 09/10/10 and could not be contacted. A search of her office failed to produce the cards. In a subsequent interview, the administrator joined the social worker. The administrator stated he was unaware the cards had not been returned, and he reported he had no knowledge of their current location. He confirmed the facility's admissions clerk had quit unexpectedly on 09/10/10. He stated it was the facility's practice for the admissions clerk to obtain the cards during the admission process, but they should be copied and returned to the responsible party. He did not know why this was not done for Resident #96.",2014-01-01
11538,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,323,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. On [DATE] at 11:00 a.m., the administrator, medical director, director of nursing, social worker (Employee #52), and the clinical care coordinator (Employee #33) were notified of the finding of immediate jeopardy. At 11:40 a.m. on [DATE], the administrator provided an action plan, which was reviewed and accepted by the nurse surveyor at 11:45 a.m. The action plan included the following steps: Resident #26 was transferred to a private room on another floor, staff was instructed to observe and record Resident #26's behavior on an hourly basis, and Resident #26's care plan was revised to reflect these actions. On [DATE] at 1:30 p.m., the nurse surveyor verified that Resident #26 was relocated, and the immediate jeopardy was removed with no deficient practice remaining. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. ""... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38's) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A QA committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD (Alzheimer's disease) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician's progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, psychosis diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: ""... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.) - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" .",2014-01-01
11539,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,520,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. "" ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: "" ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE].",2014-01-01
11463,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,224,D,,,H9I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to obtain approval from the Social Security Administration before it, while serving as an organizational representative payee, reimbursed Summersville Memorial Hospital for medical debts in arrears for one (1) of twenty-three (23) Stage II residents. Resident identifier: #28. Facility census: 49. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to Summersville Memorial Hospital's skilled nursing unit on [DATE], and expired at the facility on [DATE]. Review of the resident trust fund accounting information revealed the facility paid a total of $733.01 to Summersville Memorial Hospital from Resident #28's personal fund account maintained by the facility on [DATE], [DATE], and [DATE], for services incurred at Summersville Memorial Hospital on [DATE], [DATE], [DATE], [DATE], and [DATE] - all of which were debts made prior to her admission to the skilled nursing unit. During a telephone interview with the resident's former medical power of attorney representative (MPOA) and spouse on [DATE] at approximately 8:00 p.m., they spoke their belief that the facility should have forwarded any extra money the resident had in her personal account to the resident's burial fund rather than paying bills that were five (5), six (6), and seven (7) years old and which incurred when she resided in the acute care portion of the facility. During an interview with the staff member responsible for patient accounts (Employee #130) on [DATE] at 9:30 a.m., she said the skilled nursing unit is a subdivision of Summersville Memorial Hospital, and their tax identification numbers are the same. She handles accounts for the skilled nursing unit and explained that Resident #28's old debts to Summersville Memorial Hospital had been turned over to a collection agency. She said she assumed that, if a resident had a previous bill from any hospital or other bill (such as an unpaid electric bill), the facility managing the funds would pay outstanding debts presented. She produced evidence the Social Security Administration (SSA) designated Summersville Memorial Hospital to serve as Resident #28's organizational representative payee on [DATE]. On page 3 of the Advance Notification of Representative Payment form from the SSA dated [DATE], the facility answered ""no"" to question #11, when it asked if the claimant (Resident #28) was ""indebted to your institution for past care and maintenance"". Employee #130 stated that, at that time, the skilled nursing unit was unaware of the past due debts owed to Summersville Memorial Hospital; it was not until the bad debts were turned over to a collection agency and the past due bills were presented to the facility for payment on [DATE], [DATE], and [DATE] (totaling $733.01) that the staff at the skilled nursing unit became aware of the debt. When asked if the facility had requested permission from the SSA to pay those outstanding debts to Summersville Memorial Hospital before making the payments, Employee #130 said they had not, and she was not aware that they needed to obtain this permission, since they were the resident's representative payee. .",2014-02-01
11464,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,257,C,,,H9I611,". Based on the results of the complaint investigation (State Complaint Reference # ), it was determined the facility failed to maintain a comfortable building temperature of at least 71 degrees Fahrenheit (F). Facility census: 51. Findings include: a) The National Weather Service (NOAA: www.weather.gov/climate/) temperature archives indicate the outside temperature in the greater Beckley area, beginning on 09/26/10 and continuing through 10/04/10 - a nine (9) day period, was no greater than 69 degrees F. The daily low temperature during this time period was no greater than 58 degrees F. The lowest daily temperature during this time period was 38 degrees F. on 10/02/10. When questioned as to when the facility heating system became functional, the facility's administrator stated an attempt to activate the heating system had failed on 10/01/10 due to a faulty valve. The valve and the heating system became functional on 10/04/10. Without a functional heating system, it would not be possible to maintain the building temperature at a minimum of 71 degrees F during this time period. .",2014-02-01
11465,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,241,D,,,SHO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview and staff interview, the facility staff failed to treat residents with respect. Staff walked past Resident #71 who was requesting assistance without acknowledging her presence or her request. When interviewed, Resident #71 (who was alert and oriented) reported staff members frequently did not identify themselves to her when giving her care. The resident said she felt like staff treated her like a child. This was observed to be true for one (1) of four (4) sampled residents. Resident identifier: #71. Facility census: 118. Findings include: a) Resident #71 At the initial unannounced entrance to the facility on [DATE] at 3:30 p.m., Resident #71 was observed standing in the doorway of her room waving a water pitcher in the air and saying in a loud voice, ""I need some water. Will you get me some water?"" As she was making this request, staff members were observed to walk past her and not pay attention to her. A nurse was down the hall passing medications, and two (2) nursing assistants walked past her without saying anything. Resident #71, when interviewed at 4:10 p.m. on 10/17/10, stated she had tried to get the staff to help her several times, but ""some of them just run from you."" When asked if she knew the names of the staff members that she has difficulty getting help from, she stated, ""No, because they do not tell you their name and probably don't want you to know it."" She then named several staff members who did treat her respectfully and stated, ""They were wonderful and very nice, but some of them just run from you and ignore you."" The resident stated, ""I do not appreciate being treated like I am a child."" This surveyor turned on the call light in Resident #71's room at 4:15 p.m. on 10/17/10. The call light was promptly answered at 4:16 p.m. A nursing assistant (Employee #56) came in the room and asked, ""What do you need?"" while walking past this resident and looking at the roommate. Resident #71 told this nursing assistant, ""I have been trying to get you to help me, and you would not even stop and see what I wanted."" The nursing assistant responded, ""You caught me in a run."" The nursing assistant was asked by this surveyor what her name was, because she wore no name tag, and she was identified herself. The resident stated she did not know this employee's name, because ""The staff here never tell you their names, but she is one of the ones who ignored me earlier."" Employee #56 proceeded to assist the resident's roommate (Resident #24) to the bathroom. Another staff member then came in, and Employee #56 told her that she needed to go to the bathroom. Resident #71 then asked, ""Who is assigned to this room?"" Employee #56 told her the name of her assigned caregiver. Resident #71 stated she did not know who that was. She then stated, ""I know their names if they tell me,"" and she again named staff members by name and said, ""They treat you wonderful, but some don't even tell you their name."" Medical record review revealed Resident #71 was alert / oriented and had capacity to understand and make her own informed health care decisions. She lived alone and came to the facility following a knee replacement. She did not have any long-term or short-term memory problems and was independent with cognitive skills for daily decision-making. The social worker (Employee #53) was notified of the above observations at 10:30 a.m. on 10/18/10. At 11:00 a.m., this surveyor accompanied this social worker to interview Resident #71. The resident described to the social worker the incident that had occurred the day before, and the social worker initiated an investigation into the incident at that time. .",2014-02-01
11466,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,242,D,,,SHO311,". Based on observation, confidential family interview, and staff interview, the facility did not always honor residents' food likes and dislikes. Resident #78 was served beets for dinner, even though this was specifically listed on her tray card as one (1) of the two (2) food items this resident did not like. This was identified during one (1) random meal observation on 10/17/10. Facility census: 118. Findings include: a) Resident #78 During initial tour of the facility on 10/17/10 at 3:40 p.m., interviews were conducted with family members and alert / oriented residents. In one (10 confidential interview, a family member who visited frequently reported the facility staff did not honor residents' food preferences, stating, When you tell them you do not like something, you seem to get it anyway."" This family member did report that staff will obtain substitute food items upon request. During an observation on 10/17/10 at 6:00 p.m., a test tray was requested to replace the last tray served on the hall (to check the temperature of food items at the time of service). This tray was intended for Resident #78. The temperature of food items on the tray were within an acceptable temperature range. Observation found the meal served to Resident #78 consisted of Swedish meatballs, pasta, beets, peaches, and milk. Review of Resident #78's tray card, which lay beside the plate on her tray, disclosed two (2) items listed under ""dislikes"" - beets and green beans. According to assessment information provided by the facility, Resident #78 was not able to participate in an interview due to cognitive impairment. Her food was pureed, and she was fed by staff. She would not have been able to request a substitute for the beets. The dietary manager, who was present at the time of this observation at 6:00 p.m. on 10/17/10, verified that beets were listed as a dislike on this resident's tray card. A new tray was requested for this resident following the testing of her tray. .",2014-02-01
11467,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,356,C,,,SHO311,". Based on observation and staff interview, the facility failed to post - accurately and at the beginning of each shift - the required information to identify the staff members providing care and the census of the facility. Observation, on 10/17/10 at 3:40 p.m., found the posted nurse staffing information was dated 10/16/10, and the census information was absent. This practice has the potential to affect all residents and visitors. Facility census: 118 Findings include: a) Observation of the facility's posted nursing staffing data, on 10/17/10 at 3:40 p.m., found the posting was dated 10/16/10. The only nursing staffing data recorded on this posting was for the day shift of 10/16/10, and there was no resident census information recorded as required. An interview with the charge nurse (Employee #49), on 10/17/10 at 3:40 p.m., confirmed this information had not been updated to reflect the numbers of nursing staff or residents currently in the building.",2014-02-01
11468,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,280,D,,,SHO311,". Based on observation, staff interview, and medical record review, the facility failed to revise the nutrition care plan and Kardex used by nursing assistants caring for Resident #50 to accurately reflect the services to be furnished to the resident following a significant change in the resident's status, after she received a fracture to the right arm and became totally dependent on staff for eating. This was true for one (1) of four (4) sampled residents. Resident identifier: #50. Facility census: 118. Findings include: a) Resident #50 Observation of the evening meal, on 10/17/10 at 6:00 p.m., found Resident #50 being fed by a family member. Resident #50's right arm was in a sling, and she was not moving her arm. A second observation of this resident, in the dining room during the noon meal on 10/18/10, found her being fed by a nursing assistant; the resident was totally dependent on staff for eating and drinking. She was not initiating any movement of her right arm to participate in the task of eating. In an interview with the nursing assistant providing care to Resident #50 (Employee #26) on 10/19/10 at 10:00 a.m., Employee #26 was questioned about the amount of assistance Resident #50 required with meals. Employee #26 stated the resident could not move her right arm and she required total assistance with meals. Review of Resident #50's medical record disclosed a significant change in status minimum data set (MDS) was completed on 09/27/10. According to this assessment, the resident was totally dependent on one (1) staff member for eating. Review of her current care plan found the resident's nutrition plan was not reviewed or revised following her change in condition. The interventions listed for maintaining the resident's weight still stated, ""Assist resident with meals to extent needed."" It was not specific to the amount of staff assistance she needed with eating. This approach was written on 04/27/10, and was reviewed on 07/16/10, but it was not revised after the resident's significant change assessment on 09/27/10. Further review of the care plan found Resident #50's self-care deficit plan was revised on 09/28/10, to state she required total assistance from one (1) staff member with locomotion, eating, bathing, and personal hygiene. When questioned on 10/19/10 at 10:00 a.m. about how staff knows how much assistance a resident needs according to her/his care plan, Employee #26 said there was an ADL (activity of daily living) sheet that describes each resident's needs. The ADL sheet (Kardex) for Resident #50, when reviewed, found the resident was identified as being ""independent with set-up help only"" with eating. There was no evidence Resident #50's Kardex (the means by which the facility communicated elements of the care plan to direct care staff for each resident) had been updated to reflect a significant change in the resident's self-feeding ability.",2014-02-01
11469,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-10-07,318,D,,,UP4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of four (4) sampled residents, who had limited range of motion (ROM) of the left hand, received appropriate treatment and services to prevent further decrease in ROM. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 Review of the resident's medical record did not find any evidence that a brace was supposed to be put on the resident. Observations made on 10/06/10, during the day at 9:00 a.m., 12:00 p.m. and 2:00 p.m., did not find evidence of a brace on the resident's left hand and wrist. On 10/07/10, a brace was found on the resident's left hand at 10:25 a.m., and the nursing assistant (NA - Employee #17) was in the room providing care for the resident, when interviewed, stated he did not care for the resident on a regular basis and did not know about the splint. A licensed practical nurse (LPN - Employee #132) who provided care for the resident, when interviewed at 10:30 a.m. on 10/07/10, said she thought therapy was supposed to get the resident a new brace, but she was not sure if it had been ordered yet. At 11:00 a.m. on 10/07/10, the interim director of nursing (DON) reported the resident was ""on the therapy board"" but, due to issues with payment, therapy was only doing evaluations for her. Interview with the assessment nurse, on 10/07/10 at 1:30 p.m., found the resident did not have a care plan for a splint, as there was no physician's order for one. Interview the rehab program director (Employee #105), at 1:45 p.m. on 10/07/10, found she did not start here until July 2010 and did not know about any issues regarding this resident. Employee #105 later said the rehab program was going to pick up the resident again and try to do some therapy for her. At 2:10 p.m. on 10/07/10, the occupational therapist (OT - Employee #162) said a new brace with finger separators would be ordered for the resident, and she would set up a splinting schedule with training for the resident's family and staff. She also reported she performed a new evaluation of the resident on 10/07/10, compared it to an OT evaluation that was completed on 05/06/10, and found the resident had not lost any ROM in that hand. A review of the resident's comprehensive annual assessment, with an assessment reference date (ARD) of 05/12/10, found in Section G the resident had limited ROM of one (1) hand with full loss of voluntary movement. In Section S, the assessor noted the resident's left hand had a contracture. Review of the resident assessment protocol (RAP) for activities of daily living / functional rehabilitation potential, dated 05/19/10, found it did not address the resident's contracture. Review of the resident's current care plan, with a created date of 03/19/10, confirmed the interdisciplinary team identified the resident was at risk for loss of ROM ""r/t (related) to existing contractures of her left hand and ankle, but the care plan did not include an intervention to apply a splinting device to the resident's left hand. Review of the OT Evaluation, with a signature date of 05/11/10, noted, ""... Pt is @ (arrow pointing up) risk for contractures & presenting /c (with) (arrow pointing down) PROM (passive range of motion) in (L) UE (left upper extremity) (symbol for 'secondary to') [MEDICAL CONDITION]/[MEDICAL CONDITION] Dx ([DIAGNOSES REDACTED]. Pt would benefit from skilled OT services for contracture Mgt (management) programs (illegible) splinting, positioning & staff education for (L) UE."" found the resident to have 0-70 degree ROM in the left wrist and she was at high risk of developing a contracture due to a [DIAGNOSES REDACTED]. A request was made of Employee #105, on the afternoon of 10/07/10, for any other information about the resident's therapy plan; Employee #105 reported the only information she had was on the resident's medical record. Review of the resident's medical record found a form titled ""Rehabilitation Screening"", dated 04/01/10, with an entry by Physical Therapy which stated; ""Pt (patient) not appropriate for contracture management program due to poor rehab potential for functional outcome."" Review of an OT Rehabilitation Summary, dated 06/08/10, noted the resident was being discontinued from OT, stating, ""Pt participated in all tx (therapy) sessions and has met all LTG's (long-term goals) @ this time. Pt is currently utilizing a resting hand splint on (L) hand to assist /c positioning (in order to (arrow pointing down) risk of further contracture). ..."" The author of this entry further noted staff and family were educated on the resident's splint schedule, and the resident was to receive passive ROM before having the splint applied. Review of the 10/07/10 OT Evaluation found the long-term goal for the resident was: ""Pt to tolerate WHO (wrist-hand orthotic) /c out complaints of skin irritation / breakdown to prevent further deformity and management of (L) UE contractures."" Treatment approaches included: ""Splint Evaluation, Splint training, and Contracture management.""",2014-02-01
11470,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-10-07,312,D,,,UP4G11,". Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure staff provided necessary assistance to maintain good grooming and personal hygiene for (1) of four (4) sampled residents who was unable to do so for herself. Resident #134 did not always receive mouth care, which she was unable to do for herself. The resident expressed that she would like to get out of bed for short periods of time but was not able to get out of bed by herself and was not gotten up by staff. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 1. Observations made with a licensed practical nurse (LPN - Employee #132) and a nursing assistant (NA - Employee #17), on 10/07/10 at 10:30 a.m., found the resident's teeth had food debris on them. The resident, when interviewed, reported she had not received mouth care that day or on other days on a regular basis. She stated she had her own teeth and said she had to ask staff to clean her teeth, in order to get them taken care of. The NA reported he cleaned her teeth whenever she asked him to. The resident was observed again with the interim director of nursing (DON) at 11:00 a.m. on 10/07/10. Review of the resident's care plan, dated 06/22/09, found the resident was to be assisted with oral care as needed. - 2. Observation of the resident, on 10/06/10 at 9:00 a.m., 12:00 p.m., and 2:00 p.m. and on 10/07/10 at 10:30 a.m., found the resident in bed. When interviewed on 10/07/10 at 11:00 a.m., Resident #134 reported she would like to get up, but when she did, she often was left up too long (several hours) in the geri chair and it became uncomfortable for her. She said she would be willing to get out of bed for one (1) hour at a time, if staff would put her back to bed in a timely manner. The interim DON was present for this interview. Employee #132 (LPN), when interviewed on 10/07/01 at 10:30 a.m. during an earlier observation of the resident, reported the resident would get up for showers, to get her hair done, and to get her bed made. Review of the care plan, dated 06/02/09, found the resident would be encouraged assisted to change positions frequently and transferred with a mechanical lift using a two (2) person assist. The activities care plan note, dated 08/12/10, stated, ""Resident requires max assist w/ (with) activity intervention d/t (due to) impaired mobility. Her participation has decreased this review period due to episodes of not feeling well... Resident will attend large group activities... Her husband visits daily and stays for extended periods, as well as visits from her daughter. No sign change."" .",2014-02-01
11471,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-04,166,D,,,PYV111,". Based on a review of the resident council minutes, medical record review, resident interview, family interview, and staff interview, the facility did not ensure all complaints made by residents, families, or responsible parties were documented and investigated. In addition, the facility did not follow up with those individuals making the complaints, to let them know the outcome of the complaint investigation and the resolution to the issue. Resident identifier: #66. Facility census: 120. Findings include: a) Resident #66 During tour of the facility on 10/03/10, a family interview revealed Resident #66 had experienced some problems with having to sit in a soiled brief for a long period of time. The resident had wanted to attend a church service but had to wait for a long time before she could go, because staff was not available to change her soiled brief. On 10/04/10 at approximately 9:00 a.m., telephone contact with Resident #66's family revealed this incident took place in September 2010. The family member indicated there were problems with getting assistance from nurse aides on the last two (2) Sundays in September. The family member reported nurse aides told her they could not assist in changing Resident #66's brief until the lunch trays were picked up. The family member related that, on 09/19/10, she had complained to staff but did not put her complaint in writing. On 09/26/10, she did write a letter listing her concerns about staff not assisting Resident #66 with incontinence care. The family member put the letter under the administrator's door. The administrator confirmed this did occur and that he passed the letter along to Employee #50, the unit manager on the hall where Resident #66 lives. In an interview on 10/04/10 at approximately 11:00 a.m., Employee #50 (registered nurse unit manager) confirmed she had received this letter from the administrator. She said she investigated the family's concerns. The outcome of the investigation did reveal a nurse aide had told the family member she could not assist in changing Resident #66's brief until she finished picking up lunch trays. Employee #50 could not remember the name of this particular nurse aide. She did say she had instructed this individual to always assist a resident if they needed something done, even if they were in the process of picking up trays. Employee #50 did not have any documentation about this incident. There was no evidence of any education that had taken place with the nurse aide involved. Also, there was no evidence that the facility had contacted the family member to let them know the outcome of the investigation. On 10/04/10 at approximately 12:00 p.m., Resident #66 said she did have to wait for long periods of time on occasion to get her brief changed. She said, recently, the wait time had been reduced to twenty (20) minutes. The administrator agreed this resident needed to know what had occurred in regards to the investigation about her concerns with her brief not changed timely. He confirmed that, up to this point, that had not taken place. On 10/04/10 at approximately 12:45 p.m., review of the resident council minutes from 09/21/10 revealed the council members expressed concerns regarding call lights not being answered timely on Cherry hall. The activity director (Employee #80) indicated she had not passed this information from the council along to the unit manager of Cherry hall. The administrator agreed this information needed to passed along in a timely manner and that it had not occurred.",2014-02-01
11472,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-21,253,D,,,6HW411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, family interview, and staff interview, the facility failed to clean the floor adequately for one (1) of eight (8) sampled residents. Numerous observations of the resident's floor found it to be sticky, even after having been recently mopped. This stickiness had the potential to affect the steadiness of the gait of the resident who was known to ambulate within the room independently; it also compromised safety of others, as it had the potential to harbor bacteria that could be transmitted throughout the facility on the soles of shoes of all staff who entered the room. Resident identifier: #61. Facility census: 120. Findings include: a) Resident #61 Record review revealed Resident #61's [DIAGNOSES REDACTED]. During interview with the nurse unit manager (Employee #51) on 10/19/10 at 4:30 p.m., she said Resident #61's physician orders [REDACTED]. Resident #61 experienced a fall in early October, but x-rays completed af the emergency room ruled out any new fractures; she was wearing hipsters at the time of the fall. Currently, she was on the waiting list for inpatient care at a behavioral health / medicine center related to problem behaviors that were not able to successfully be redirected. Observation of the resident throughout the survey found she walked in her room independently, ambulated to the toilet independently, and was observed closing the door to the hallway on more than one (1) occasion. Observation of the resident's floor, on 10/18/10 at 3:00 p.m., revealed the floor was sticky in a wide area around all sides of the bed. The sticky floor was also observed by the life-safety code (LSC) surveyor who brought it to the attention of Employee #133 (the environmental service director), who immediately called staff to mop the floor. Observation, on 10/18/10 at 5:30 p.m., found the floor had dried and was just as sticky as it had been previously. Observation of the floor, on 10/19/10 at 9:00 a.m., found the floor to be sticky all around the bed. This was called to the attention of the LSC surveyor, who again notified the environmental service director, who again called staff to mop the floor. After drying, the floor remained sticky in places. During an interview on 10/19/10 at approximately 11:00 a.m., Employee #133 said numerous members of the housekeeping staff had been out of medical leave in recent times, which had cut down their daily number of traditional full-time housekeeping staff on duty. Observation of the floor in Resident #61's room, on 10/20/10 at 9:05 a.m., found the floor to be sticky in one (1) small area, but this was an improvement over observations made on the preceding two (2) days. Review of recent resident / family grievances found one dated 09/30/10, related to the sanitation of Resident #51's room. During a telephone interview with this family member on 10/18/10 at 7:00 p.m., she acknowledged the room had been cleaned the week of her request, but she had issues with the cleanliness of the room during the following week, as it related to allegedly finding mouse droppings on the floor on 10/07/10. She said she found Resident #51's floor sticky on the left side of the bed where staff sat while feeding him. Review of recent resident / family grievances found one dated 09/22/10 from Resident #27, who complained his room was not cleaned even when housekeeping staff was asked by the resident to do so. This grievance was followed up by the facility. Review of the resolution portion of the grievance found a note that, on 10/03/10, housekeeping again did not clean his room. Review of recent resident / family grievances found one dated 09/23/10, where Resident #117's family member complained the resident's room was ""filthy ... mopped but not swept"". Facility's resolution included having the room deep cleaned 10/05/10, with follow-up contact with the family. Review of the 09/21/10 Resident Council meeting minutes found three (3) residents (names not identified) complained of housekeeping staff not cleaning their room adequately. During an interview with the administrator on 10/19/10 at approximately 10:00 a.m., he said the facility, in recent weeks, had adopted a different mopping product for a trial on a couple halls which included the 200 hall where Resident #61 resided. When informed of the persistent stickiness of the floor in Resident #61's room even after mopping, he said it was probably time to complete an evaluation of the product change. .",2014-02-01
11473,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-21,309,D,,,6HW411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to monitor the effectiveness of treatment after administration of Tylenol for a new development of fever and in the presence of other symptoms and complaints; the facility also failed to monitor the temperature of a dependent resident with a history of repeated urinary tract infections after a new onset of fever early in the morning. This was evident for one (1) of six (6) sampled residents. Resident identifier: #51. Facility census: 120. Findings include: a) Resident #51 During an interview via telephone on 10/18/10, Resident #51's family member stated that, on 01/10/10 Resident #51 developed a high fever and was medicated with a fever-reducing medication, and five (5) hours elapsed before his temperature was re-checked by staff. By this time, he was totally unresponsive and the fever had elevated even more. Subsequently, he was transported to the hospital for a twelve (12) day stay. Upon his return to the facility, the pressure ulcer on his coccyx had worsened to a Stage IV wound, and he required a wound VAC after the area was surgically debrided during the hospitalization . Medical record review revealed Resident #51's temperature was 100.9 degrees Fahrenheit (F) on 01/10/10 at 3:30 p.m., and he was medicated with [MEDICATION NAME]. The physician was notified, and new orders were received for a urinalysis and culture to be obtained the following day. Further medical record review revealed that, at 5:30 p.m. on 01/01/10, he refused dinner and complained of not feeling well. The nurse documented his refusal to go to the emergency room . There was no evidence that his temperature was monitored at this time, to ascertain whether the [MEDICATION NAME] was effective in reducing his temperature, and there was not evidence to reflect the family was notified of the fever. It was not until 8:00 p.m. on 01/01/10 that the nurse again assessed him again; she documented his temperature had risen to 104.7 degrees F and he was ""non-responsive"" and had no ""appropriate pain response"". He was medicated with Tylenol per standing order for fever and was transferred to the emergency room at 8:30 p.m., where he was admitted and subsequently spent the following twelve (12) days. During an interview with the interim director of nursing (DON) on 10/19/10 at approximately 4:00 p.m., she said there was no policy regarding reassessing a resident's temperature after he/she was identified as having a new onset of fever; rather, it was left to the nurse's discretion. Per request, the DON and a medical records staff member (Employee #50) said they would try to locate and copy any documentation that could be found in addition to the nursing notes for 01/10/10 which gave evidence of temperature assessments within that five (5) hour time frame. However, none was produced. Observation, on 10/20/10 at 9:00 a.m., found Resident #51 was not in the facility. Staff interview found he was sent to the emergency room this morning around 8:00 a.m. Record review, on 10/21/10, revealed a nursing note dated 10/19/10 at 5:57 a.m., documenting the resident had a temperature at 101.4 degrees F and was medicated with Tylenol 650 mg every ""4 hours PRN (as needed) up to 3 doses. If temp (temperature) persists call MD (medical doctor)."" Record review revealed his temperature was checked once again at 9:00 a.m. on 10/19/10 and was afebrile at 98.5 degrees. Further record review revealed no evidence that his temperature was assessed again until the following morning, twenty-one (21) hours later, on 10/20/10 at 6:12 a.m., when it was found to be 103.1 degrees F. He was medicated with Tylenol, and the physician was paged. At 8:10 a.m. on 10/20/10, the nurse recorded the resident ""remains confused & lethargic. Temp. 102.1"", and orders had been received to send him to the emergency room for evaluation and treatment. Record review found he was transferred to the emergency room at 8:28 a.m., and returned to the facility on [DATE] at 12:59 a.m., with a [DIAGNOSES REDACTED]. During an interview with the nurse unit manager (Employee #51) on 10/21/10 at 10:00 a.m., she was unable to produce evidence that this resident's temperature had been assessed with [REDACTED]. She stated the nurse from day shift yesterday (10/19/10) may have forgotten to record a temperature assessment, as well as the 7:00 p.m. to 7:00 a.m. She also said the new onset of fever for Resident #51 had not been noted on a 24-hour shift report.",2014-02-01
11474,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,328,D,,,6HW412,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure one (1) of ten (10) sampled residents received the maximum benefit of each aerosolized treatment ordered by her physician. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's order permitting her to self-administer the aerosolized treatments; however, there was no evidence the interdisciplinary team completed an assessment to ensure the resident was capable of reliably self-administering these treatments, and this self-administration of aerosolized medications was not addressed on her care plan. Licensed nursing staff was aware Resident #111 did not self-administer these treatments in an effective manner, and they did not provide additional monitoring / supervision to ensure she received the maximum benefit of each treatment. Additionally, licensed nursing staff did not complete pre- and post-treatment assessments that would allow them to determine whether the treatments were effective. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's order, dated 11/23/10, stated, ""Res (resident) may administer [MEDICATION NAME] / Atrovent treatments herself."" An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's minimum data set assessment (MDS) history, beginning with an MDS dated [DATE] and continuing through the most recent MDS dated [DATE], revealed the resident was identified as being unable to self-medicate. Review of the resident's medical record failed to find evidence the resident was assessed for the ability to self-medicate. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as ""Exhibiting or is at risk for complications related to [MEDICAL CONDITION]"", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's order was written to permit this on 11/23/10. -- 4. The resident, when interviewed again on 12/06/10 at 4:15 p.m., reported she did not receive her 5:00 a.m. nebulizer treatment either. She said that, when the nurse set up the nebulizer, she was smoking and when she returned from smoking, most of the medication in the cup to the nebulizer had drained from the cup. She tried to utilize the medication remaining in the cup and it was not effective. She stated that, when this happens, she becomes short of breath. -- 5. A subsequent interview with Employee #21, on 12/06/10 at 4:30 p.m., found the resident's next scheduled nebulizer treatment was due at 5:00 p.m., but she would wait until 5:45 p.m. before administering the next treatment. This would only allow two (2) hours and forty five (45) minutes between treatments. Employee #21, when asked if the nurse on the night shift had reported to her that Resident #111 did not receive an effective treatment at 5:00 a.m., responded that she did not. The nurse reported that she marks the treatment as given on the MAR indicated [REDACTED]. The nurse stated she did not assess the resident's heart rate, respiratory rate, and breath sounds prior to initiating a treatment and after each treatment was finished. -- 6. Review of the facility's policy titled ""2.12 Medications: Self Administration"" (effective 06/01/96 and revised 01/01/04) revealed the following, ""Process: ""1. When a customer requests medication self administration, initiate the process to assess customer's capability. The customer must meet the follow criteria. ""1.1. Be able to demonstrate: ""1.1.1. Knowledge of medications and medication schedule ""1.1.2. Self-administration including use of packaging, reading label, open containers; and ""1.1.3. Ability to administer medications properly, e.g., insulin / syringe, eye drops, inhalers as needed. ""2. If assessment indicates customer is capable of medication self-administration, notify physician to obtain order. ""3. Address medication self-administration in customer's care plan. Include plan for: ""3.1. Storage, location of medications, and documentation of medication administration; ""3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and ""3.3. Ongoing monitoring and reassessing of customer's capacity. ""4. Securing medications at the nursing station. Keep a limited quantity in a locked drawer at customer's bedside. Assure that customer and nursing both have a key. ""5. Instruct customer in medication self-administration procedure. Include: ""5.1. Obtaining medication ""5.2. Administering medication according to physician order; ""5.3. Recording administration on documentation record. ""6. Monitor customer to assure medication is administered as ordered and for effectiveness and/or side effects of medication. ""6.1. Notify physician of any side effects of changes in condition that may require medication adjustment. ""6.2. Notify physician and care plan team if customer demonstrates decrease in capability for medication self-administration. ""7. Adjust plan for medication self-administration as indicated. ""8. Document: ""8.1. Customer's request and assessment of capability in Nurses' Notes or progress notes; ""8.2. Plan for storage, location, documentation, education, and monitoring on customer's care plan; ""8.3. Ongoing monitoring of customer's capability in Nurses' Notes."" -- 7. Review of the ""Assessment for Self-Administration of Medications"" (dated 1992), found the following instructions: ""Before performing this assessment, verify that there is a physician order in the resident's chart for self-administration of the specific medication under consideration and that the resident has signed the appropriate document stating the desire to self-administer his/her own medication. Proceed by checking the appropriate response below for each of the 19 items listed. The resident must be able to perform each step indicated below prior to beginning self-administration of medications. The interdisciplinary team will be responsible for approving self-medication using the assessment as a guide."" Item #19 of the assessment asked, ""Can administer inhalant medication with proper procedure?"" -- 8. Review of the resident's MAR found the form used for documenting self-administration of medications titled ""Self Medication Administration Record"" was not utilized. -- 9. Review of the facility policy titled ""11.21 Small Volume Nebulizer"" (dated 01/01/04 and revised 06/01/04), revealed at Item #8, before a nurse administered medications utilizing a nebulizer, the nurse was supposed to: ""Assess the patient's heart rate, respiratory rate, and breath sound prior to initiating treatment."" Item #20 stated, ""Upon completion of the treatment, check patient's heart rate, respiratory rate, and breath sounds."" -- 10. On 12/07/10 at 10:00 a.m., the interim director of nursing was interviewed and additional information was requested. As of exit on 12/09/10 at 12:00 p.m., no additional information was provided with respect to the above concerns. .",2014-02-01
11475,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,280,D,,,6HW412,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed, for one (1) of ten (10) sampled residents, to revise the resident's care plan to address her self-administration of aerosolized medications after an order was received from her physician to permit this. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's orders [REDACTED]."" An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as ""Exhibiting or is at risk for complications related to [MEDICAL CONDITION]"", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's orders [REDACTED]. -- 4. Review of the facility's policy titled ""2.12 Medications: Self Administration"" (effective 06/01/96 and revised 01/01/04) revealed the following under the heading ""Process"": ""3. Address medication self-administration in customer's care plan. Include plan for: ""3.1. Storage, location of medications, and documentation of medication administration; ""3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and ""3.3. Ongoing monitoring and reassessing of customer's capacity. .",2014-02-01
11476,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-10-14,164,E,,,S21C11,". Based on observation, staff interview, and a confidential resident group interview, the facility failed to ensure resident privacy was maintained during showers. The men's and women's shower rooms shared a common whirlpool area, and the privacy curtains separating these areas could not be pulled closed to ensure privacy during bathing. This had the potential to affect any resident showered in the central shower rooms at the facility. Facility census: 56. Findings include: a) During a tour of the facility on 10/13/10 at 2:00 p.m., the men's and women's shower rooms were visited by two (2) health facility surveyors. The doors to the shower rooms were separate, but once inside the shower rooms, the men's and women's rooms were connected via a common whirlpool area with full visual access from either side. There were tracks for two (2) sets of privacy curtains, one (1) on either side of the whirl pool area. The only side that had privacy curtains was located on the women's side, and one (1) of the surveyors was unable to pull closed the privacy curtains on this side. The privacy curtains were observed with the facility's administrator at 2:05 p.m. with both surveyors present. The administrator reported that men and women were not showered at the same time. Two (2) nursing assistants (Employees #7 and #54), whom the administrator indicated were shower aides for that day, were interviewed. They indicated they showered about thirty (30) residents on that particular day and finished before noon. They said they did not shower men and women at the same time. During a resident group interview on 10/14/10 at approximately 3:00 p.m., two (2) of four (4) female residents in the group reported they were given showers within the past week while men were in the common shower area at the same time. They reported the privacy curtains could not be pulled all the way closed in order to prevent others from observing while they are taking a shower. They also reported they were able to see the male residents in the shower. This was confirmed during a second observation by one (1) of the health facility surveyors just after the group interview.",2014-02-01
11477,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-10-14,280,D,,,LTYG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to address adjustment issues this resident faced. Resident #28 had [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 0.5 mg twice a day for anxiety / agitation. He also received [MEDICATION NAME] 50 mg once a day for depression, as well as Mirtazepine ([MEDICATION NAME])[MEDICATION NAME](orally disintegrating tablets) 15 mg once a day at bedtime for depression. The care plan addressed specifics as to how the facility would monitor the resident's behavior to protect and ensure the safety of others. However, it failed to address the resident's relocation to a new environment and associated adjustment difficulties, especially in view of his pre-existing [DIAGNOSES REDACTED]. On 10/13/10, medical record review for Resident #28 revealed nursing staff had observed the resident talking to himself in his room on or near 09/29/10. The staff member identified this as a new behavior. Another staff member overheard the resident threatening to harm an incapacitated resident on 09/27/10. On 10/14/10 at approximately 4:00 p.m., the administrator and director of nursing confirmed the facility's interdisciplinary team had not addressed in the care plan how the move would impact the resident's psychosocial well-being. They agreed this was a significant life-changing event for someone with dementia, anxiety, and depression. They also agreed the care plan should have revised with goals, and interventions to assist the resident in reaching the goals, to promote the resident's highest practicable level of well-being.",2014-02-01
11478,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-10-06,285,D,,,4XPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the WV Medicaid program manual for nursing facilities, the facility failed to coordinate their assessments with the preadmission screening and resident review (PASRR) program under Medicaid as required. The facility readmitted a resident from an inpatient psychiatric stay prior to receiving approval by the State-designated reviewing agency - West Virginia Medical Institute (WVMI), which resulted in the resident having no payer source to cover his continued stay at the facility when it was determined by WVMI that he was no longer medical eligible for nursing home placement under WV Medicaid criteria. Resident identifier: #56. Facility census: 112. Findings include: a) Resident #56 Record review revealed Resident #56 came to the facility on [DATE] with a pre-admission screening form (PAS-2000) signed by the physician on 01/18/10, who indicated his primary [DIAGNOSES REDACTED]. This PAS-2000 was reviewed by WVMI on 01/20/10, at which time the reviewer determined Resident #56 was medically eligible, under the WV Medicaid criteria, for nursing facility services and that a Level II evaluation was necessary. A Level II evaluator determined Resident #56 did not require specialized services for mental illness or mental [MEDICAL CONDITION] on 01/22/10. Resident #56's initial PAS-2000 indicated he was appropriate for nursing home placement for a period of up to six (6) months, after which another PAS-2000 would have to be completed for his nursing home stay to continue to be paid for by WV Medicaid. During this six-month period, Resident #56 was admitted for inpatient psychiatric services from 05/28/10 until 06/09/10, when he was readmitted to the nursing home. A second PAS-2000, signed by a physician on 06/15/10, indicated Resident #56 needed nursing home services and was not likely to eventually return home. On 06/17/10, a reviewer from WVMI denied the request for nursing home admission for Resident #56, stating he was ""ineligible for long-term care (nursing home) admission based upon WV Medicaid criteria."" This determination was made after Resident #56 had already been readmitted to the nursing facility, which resulted in the resident having no payer source to pay for his continued stay in the nursing home. In an interview on 10/06/10 at approximately 2:30 p.m., the social worker (Employee #1), director of nursing (Employee #2), and administrator (Employee #3) all indicated they did not know the resident needed an approved PAS-2000 prior to his readmission at the facility from an inpatient psychiatric stay. The nursing facility manual, Chapter 514 Section - 514.8.2 states: ""To qualify medically for the nursing facility Medicaid benefit, an individual must need direct nursing care twenty-four (24) hours a day, seven (7) days a week. The Bureau has designated a tool known as the Pre-Admission Screening form (PAS) to be utilized for physician certification of the medical needs of individuals applying for Medicaid benefit .... ""Each nursing facility must have an original pre-admission screening tool to qualify the individual for Medicaid and to meet the federal PASRR requirements. Should the receiving nursing facility fail to obtain an approved assessment prior to admission of a Medicaid eligible individual, the Medicaid program cannot pay for services. The individual cannot be charged for the cost of care during this non-covered period. ""A Medicaid recipient who converts from Medicare Part A coverage to Medicaid does not need a new assessment to receive the Medicaid benefit. Medicaid coverage can be reinstated as long as a Medicaid denial letter has been issued. ""A new medical assessment must be done for Medicaid eligibility for the nursing facility resident for all of the following situations: ""- Application for the Medicaid nursing facility benefit; ""- Transfer from one nursing facility to another; ""- Previous resident returning from any setting other than an acute care hospital; ""- Resident transferred to an acute care hospital, then to a distinct skilled nursing unit, and then returns to the original nursing facility; and ""- Resident converts from private pay to Medicaid."" As Resident #56 was returning from a setting other than an acute care hospital, a new PAS-2000 was required prior to his re-admission to the nursing facility.",2014-02-01
11479,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,278,B,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at 1:05 p.m., confirmed the resident was not on a toileting plan but was checked regularly for bladder incontinence. d) Resident #81 Review (on 01/06/09) of the quarterly MDS, completed on 11/23/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at about 1:00 p.m., confirmed the resident was not on a toileting plan. .",2014-02-01
11480,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,279,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: ""Refer to the physical restraint / enabler assessment."" 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, ""Refer to the physical restraint / enabler assessment."" The goal associated with this problem was ""(Resident) will be free of negative effects with the use of an enabler."" This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which, when reviewed, did not refer to the lap buddy in any way); refer to the falls assessment prevention and management plan of care (which did not include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy): prevention and management plan of care; maintain resident bowel and bladder routine; educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was incomplete). The care plan for this resident's lap buddy use did not specify the problem necessitating the application of the device. Additionally, record review revealed the resident became agitated and had sustained injuries when the device was applied, and this response was not addressed in the resident's care plan. b) Resident #10 Review of the interdisciplinary care plan for Resident #10, found a fifty (50) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan stated, ""Recent or chronic history of incontinence. Contributing factors included laxative use PRN and cognitive / perceptual impairment, loss of sphincter control, and decreased physical activity."" One (1) goal for problem statement was: ""Will ingest adequate fluids evidenced by resident's skin turgor."" Other goals were: ""Will have bowel movement every three days"" and ""Will be cooperative with assisted toileting."" The interventions to assist with achievement of these goals included, ""See nutritional care plan"" and ""See skin integrity prevention and management plan of care."" The stated interventions did not address the identified problem and would not lead to achievement of the established goals. c) Resident #97 1. Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized to address Resident #97's pain. 2. The resident's care plan also contained the following problem statement: ""Refer to the physical restraint / enabler assessment."" The goal stated: ""Will be free of negative effects with the use of an enabler."" (There was no mention about how the enabling device was intended to improve the resident's functionality.) One (1) intervention simply stated what device was to be used (1/2 top side rail) to aid in turning and reposition. The only other intervention was ""Refer to the mood and behavior symptom plan of care."" Review of the mood and behavior plan of care found no interventions related to the use of an enabler. There were no interventions written to assist in achieving the goal established. 3. The director of nursing (DON - Employee #2) was made aware of the inconsistencies in Resident #97's care plan at 10:00 a.m. on 01/08/09. She stated she was aware there were a lot of pages in the care plan, but this was the way their corporation required them to do the care plans. She was made aware that the resident's true problems often could not be identified and the treatment they were to receiving often did not match the care plans. d) Resident #28 Medical record review, on 01/06/09 at 1:32 p.m., revealed Resident #28 was on several medications for moods / behaviors, including [MEDICATION NAME] 12.5 mg via g tube BID (two-times-a-day), [MEDICATION NAME] 0.5 mg via g tube TID (three-times-a-day), and [MEDICATION NAME] 10 mg via g tube QD (every day). Review of the resident's most current care plan, dated 11/26/08, found the facility identified the resident was at risk for depression as evidence by ""unhappy behavior symptoms"" and persistent anger with self or others. The goal included reduction / elimination of unhappy behavior symptoms. Interventions to achieve the goal included: ""offer time to express feelings and concerns; separate from stressful situations; 1:1 (one on one) conversation to maintain trust of staff; offer reassurance; and depression scale q3 (every three) months."" Another problem was behavioral symptoms that may be harmful to self or others or interfere with function or care as evidence by yells out loud and grabs, combative with staff. The goal included no injury to self or others. Interventions included: ""administer medications, see nsg (nursing) mar (medication administration record), redirect to activity of 1:1 diversion, offer time to express feelings and concerns, separate from stressful situations, redirect to act. or 1:1 act (activity or one-on-one activity) offer to call son."" Review of the resident's minimum data set assessment (MDS), dated [DATE], revealed Resident #28 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited repetitive verbalizations, repetitive anxious complaints, sad pained worried facial expressions crying and tearfulness (of which all were easily altered). Review of the behavior tracking report, from 06/01/08 through 11/30/08, found the following: - 06/17/08 - crying and ""mood persistence"" (each one time). - 07/27/08 - crying - 08/08/08 - crying and ""mood persistence"" - 08/21/08 and 08/30/08 - crying - 09/02/08 and 09/03/08 - physical abuse (a behavior which was not described) - 10/03/08 - crying - 10/04/08 - crying and ""mood persistence"" - 10/06/08 - sad / pained / worried facial expression and ""mood persistence"" - 10/07/08 - crying two (2) times and ""mood persistence"" - 10/26/08 - crying and repetitive verbal, unrealistic fears, repetitive anxious, sad / pained / worried facial expression, and ""mood persistence"" - 10/27/08 - crying and ""mood persistence"" - 11/15/08, 11/21/08, and 11/25/08 - crying and ""mood persistence"" The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. e) Resident #62 Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several medications for moods / behaviors. Her physician's orders [REDACTED]. - On 10/31/07 - [MEDICATION NAME] tablets 20 mg PO (by mouth) Q AM (every morning) and [MEDICATION NAME] 50 mg po BID; - On 02/20/08 - [MEDICATION NAME] 200 mg PO QD and [MEDICATION NAME] 100 mg PO QD; - On 05/15/08 - [MEDICATION NAME] 5 mg po BID; - On 11/12/08 - [MEDICATION NAME] 0.25 mg PO Q AM, [MEDICATION NAME] 0.5 mg PO Q HS (every night), and [MEDICATION NAME] ER 250 mg PO QD. Review of resident's current care plan, last updated on 10/15/08, revealed the interdisciplinary care team identified Resident #62 exhibited behavioral symptoms that may be harmful to self and/or others or that interfered with function or care, as evidenced by ""cognitive deficit Alzheimer's, doesn't understand the need to be here."" The goals associated with this problem statement were no injury to self or others and to reduce the frequency of behavioral symptoms. Interventions included: ""1:1 conservation to calm, reminisce, see act poc (see activity plan of care), offer to call family."" Another problem statement addressed: ""Socially inappropriate - yells out loud for nurses to help her. Yells that she's sick or has to go to the bathroom; anxious / repetitive questions, statements."" The goal associated with this problem statement was: ""Will exhibit socially appropriate behaviors."" Intervention included: ""offer reassurance, encourage rest encourage activities, separate from stressful situations, offer to call son, take for a walk."" Review of the resident's most recent MDS, dated [DATE], revealed Resident #62 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited negative statements, repetitive questions, repetitive verbalizations, unrealistic fears, recurrent statements that something terrible was about to happen, repetitive anxious complaints, [MEDICAL CONDITION], sad / pained / worried facial expressions, crying / tearfulness, and repetitive movements (all of which were not easily altered). Additionally, the assessor identified that the resident exhibited wandering, verbally abusive, physical abusive, and socially inappropriate behaviors and resists care (all of which were not easily altered). Review of the behavior tracking report, from 09/11/08 through 10/10/08, revealed she exhibited behaviors on only four (4) days during the two-month period (09/30/08, 10/06/08, 10/07/08, and 10/10/08). The behaviors being tracked were: negative statements, repetitive questions, repetitive verbal, persistent anger, self deprecation, unrealistic fears, terrible things to happen, repetitive health, unpleasant mood, [MEDICAL CONDITION], sad / pained / worried facial expression, crying, repetitive physical, mood persistence, wandering, wandering altercation, verbal abuse, verbal altercation, physical abuse, physical altercation, socially inappropriate, social altercations, and resists care. Specific examples of these behaviors (such as what constituted ""mood persistence"") were not identified in either the resident's assessments, care plan, or behavior tracking report. The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. f) Resident # 81 Medical record review (on 01/06/09) of the physical restraint / enabler plan of care, dated 09/24/08, revealed the following problem statement: ""Refer to the physical restraint / enabler assessment."" The associated goal was: ""Will be free of negative effects with the use of the enabler"". The plan did not identify the reason for use of the enabler and did not establish a goal based on the assessment and the use of the enabler. .",2014-02-01
11481,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,309,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an ""as needed"" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. A review of the physician orders [REDACTED]. The resident also had a PRN order for [MEDICATION NAME]. There was no evidence in Resident #97 that staff offered the [MEDICATION NAME] for breakthrough pain between the scheduled doses of [MEDICATION NAME]. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized, and the stated interventions were not initiated when the resident expressed that her routine pain medication was not effective. The nurse did not offer her the PRN [MEDICATION NAME] for breakthrough pain, and there was no evidence that, when the resident expressed continued pain between the routine doses of [MEDICATION NAME], the nurse assessed the pain (type, location, severity, etc.) and provided alternate interventions. The director of nursing (DON - Employee #2) was notified, on 01/07/09 at 6:30 p.m., of the episodes of pain which were not thoroughly assessed and treated by the nurse. The DON agreed the nurse did not intervene according to the standards of practice when the resident expressed the need for additional pain medication. b) Resident #10 1. The physician' s orders, dated 01/01/09, contained an entry for: ""0.45% NS (normal saline) infuse at 75cc/hr PRN if not eating / drinking."" Medical record review revealed the resident was not eating, and she was receiving comfort care. The family did not desire a feeding tube, but they did want the IV fluids for hydration. This resident was observed on 01/05/09 at 2:30 p.m. with IV fluids infusing into her right hand. Another observation, at 6:00 p.m. on 01/06/09, found two (2) different nursing assistants attempting to feed this resident. She would not eat, spitting the food out and turning her head. She also was not drinking. The IV fluids were infusing at 75cc/hour at that time. Review of the medical record revealed staff was not accurately recording the amounts of fluid received by the resident on a daily basis. This IV fluid was ordered ""as needed"" and not continuously, and there was no record of accurate intake of these fluids per shift. There was no intake and output (I&O) record in the medical record on 01/01/09 or 01/05/09. It could not be determined, from the medical record, how much fluid intake this resident. Additionally, the resident's fluid output was not recorded on the I&O worksheets. This resident had an indwelling Foley urinary catheter, which would facilitate the measurement of the resident's urinary output. However, the urinary output was not recorded, and there was no evidence that anyone had compared the resident's output to the intake to check for a fluid balance. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR, there was no documentation to reflect IV fluids were administered on 01/06/09, and there was no intake records found for that day; however, this surveyor observed IV fluids being administered on 01/06/09 at a rate of 75cc/hour. During an interview with the minimum data set assessment (MDS) nurse (Employee #23) at 10:45 a.m. on 01/07/09, on she was asked if fluid I&Os were recorded elsewhere. She was unable to locate any further records of fluid I&O, and she verified there was no evidence the resident's fluid balance was being adequately monitored. 2. Resident #10 also had contractures to both hands. The resident's most current plan, updated on 11/25/08, specified as an intervention: ""Rolled up washcloths in left hand at all times."" The care plan also stated, ""Place resting splint on right hand from 9:00 a.m. to 3:30 p.m.""; staff was to place a rolled up washcloth in her right hand after the splint was removed. On multiple occasions on 01/05/09, 01/06/09, 01/07/09, and 01/08/09, observation found nothing in this resident's hands to prevent further contractures. On two (2) different occasions, the resident was wearing socks over her hands, but there were no devices in place to address the resident's contractures. During an interview with the MDS nurse at 10:45 a.m. on 01/07/09, she stated this resident should have had something for positioning in her hands due to the contractures. c) Resident #40 1. Medical record review, observation, and staff interview (on 01/06/09 and 01/07/09) revealed Resident #40 did not have on the ""double Geri gloves at all times"" as ordered by her physician. Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found the geri gloves were above her wrist and were not the double gloves. 2. The resident also had a physician's orders [REDACTED].@ all times"". Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found both heels were resting directly on the beds. .",2014-02-01
11482,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,371,F,,,UFEY11,"Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. .",2014-02-01
11483,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,441,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing. After the incontinence brief was removed and the resident was cleansed, the nursing assistant used her contaminated gloved hands to pull up the resident's covers and pull back the privacy curtain between the two (2) beds. During interview with the director of nursing (DON - Employee #2) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). b) Resident #65 During record review on 01/06/09, the record revealed Resident #65 had a urinalysis laboratory report showing a UTI, reported on 11/06/08. This urinalysis / urine culture report identified E. coli as the infecting organism. The record contained another urinalysis laboratory report showing a UTI, reported on 10/25/08. This urinalysis / urine culture report identified Citrobacter freundii as the infecting organism. On 01/07/09, review of the infection control report / log for November 2008 did not show this resident's name, the presence of a UTI, or the cultures infectious. Review of the October 2008 infection control report / log, on 01/07/09, revealed this resident's name and ""UTI""; however, the infecting organism was not noted. On 01/07/09 at 6:30 p.m., the DON (who was also the infection control nurse) was made aware of these findings. No additional documentation was provided. c) Resident #75 Record review, on 01/07/09, revealed Resident #75 was seen at the emergency department at a local hospital on [DATE] - 12/19/08. The ""Hospital to Extended Care Facility Transfer Information"" form (dated 12/19/08) recorded a [DIAGNOSES REDACTED]. The facility subsequently obtained the laboratory report and provided copy to the surveyor on 01/08/09. This urine culture laboratory report identified Proteus mirabilis as the infecting organism. On 01/08/09, review of the infection control report / log for December 2008 revealed this resident's name with ""URI"" (upper respiratory infection) listed. The log did not show the resident's UTI or the infecting organism. d) Resident #35 Record review for Resident #35 revealed a urinalysis (UA) done on 12/19/08. The laboratory results indicated this resident had a UTI with E. coli present. This resident's UTI was treated, but there was no evidence the facility had monitored the infection and investigated the reason for this infection. This type of infection is often caused by inadequate perineal care. There was no evidence that the facility placed this resident on the facility's infection tracking form for tracking or trending. e) Resident #97 During an interview on 01/06/09, this resident stated, ""I have urinary tract infections a lot, and I am careful how I wash."" The resident then explained that she does not like the facility staff to give her a bath or wash her, because ""they do not know how to do it right to keep you from getting an infection."" She said, ""When I came in here, one of the nursing assistants gave me a shower and washed me back to front, and I will not let them wash me anymore."" The resident stated she ""reported this to the desk"" and now they let her take a bath herself. --- Part II -- Based on random observations, the facility failed to ensure staff distributed ice water in a manner to prevent the potential development and transmission of disease and infection. This was evident for all the residents on the 300 Hall and 400 Hall who were allowed to have water pitchers at the bedside. Facility census: 113. a) First observation 01/05/09 at 3:00 p.m., and shortly thereafter on the 300 Hall, a nursing assistant was observed during ice pass holding water pitchers directly over the open ice chest while dipping ice into the residents' used water pitchers, a practice which could potentially transmit microorganisms from the exterior surface of the dirty pitcher to the clean ice which was served to the residents on that hall. The nursing assistant was observed filling two (2) pitchers from room [ROOM NUMBER], one (1) pitcher from room [ROOM NUMBER], and two (2) pitchers from room [ROOM NUMBER] in this manner. At 3:15 p.m., the above observations were reported to the nurse (Employee #27), who immediately spoke with the nursing assistant about the matter. On the 400 Hall, three (3) nursing assistants were observed during ice pass dipping ice into residents' used water pitchers directly over the open ice chest below. At 3:20 p.m., 3:21 p.m., and 3:22 p.m., three (3) nursing assistants were each observed filling two (2) pitchers at a time in this manner, and one (1) single pitcher filled at 3:25 p.m. At 3:26 p.m., this practice was relayed to the corporate nurse (Employee #100), as she also observed one (1) of the three (3) nursing assistants dipping ice into two (2) pitchers directly over the ice chest, and she immediately addressed the situation with that nursing assistant. The corporate nurse then relayed information regarding this practice of dispensing ice to the administrator (Employee #1). b) Second ice pass observation During an observation of medication administration on 01/06/09 at 9:10 a.m., a nursing assistant (Employee #58) was observed passing ice to the residents on the 400 hall. Employee #58 was observed to enter room [ROOM NUMBER] and remove two (2) ice pitchers. The nursing assistant held the ice pitchers over the ice chest and filled them with ice. Following the previous day's observations and management interventions, staff continued to pass ice in a manner which could lead to the spread of microorganisms. .",2014-02-01
11484,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,328,E,,,UFEY11,"Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: ""Label nasal cannula (also humidifier) with resident name, date, and liter flow."" Review of Section 2.2.1. General Requirements found, under the procedure for the subject of Disposable Equipment Change Schedule subset 1.n.: ""02 (Oxygen) delivery devices - for example Venturi masks, nasal cannulas, oxygen supply tubings - every 5 days and PRN (as needed)."" When asked on 01/06/09 approximately 2:30 p.m., the director of nursing (DON - Employee #2) said the facility's policy was to change nasal cannulas and tubings weekly. On 01/07/09 at approximately 6:30 p.m., the above findings were reported to the DON. .",2014-02-01
11485,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,164,E,,,UFEY11,"Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the shower experience lacked privacy, she said she can see the breasts of residents in the adjoining shower while she is being showered. When asked about the blocks that extended part of the way up the shower stalls on each side facing the other stall, she replied she could see the residents' breasts over the blocks, as they were not high enough to block the view. When asked about the shower curtain between the stalls, she replied she had not ever noticed if there was a shower curtain between the stalls. She clarified she also saw the ""bottoms"" of other residents when they were brought out of the shower stall naked. When asked if there was a curtain between the showers and the main door, she replied in the affirmative but stated, for example, when she was brought in for a shower and was waiting her turn to get in, she could see the bodies of other residents around the curtains, as the curtains were not pulled fully closed and/or gapped open. e) The above findings were reported to the director of nursing (DON - Employee #2) at approximately 6:30 p.m. on 01/07/09. She stated she was not aware of these findings in the facility. .",2014-02-01
11486,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,221,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as ""enablers"" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan directing staff to apply ""socks to hands at all times"". The medical symptom for the use of this physical restraint was ""prevent scratching face, removal of O2 (oxygen)"". This care plan then said, ""D/C (discontinue) 12/19/2008."" During an interview with the minimum data set assessment (MDS) nurse (Employee #23) on 01/07/08 at 10:45 a.m., the MDS nurse verified that the intervention to put socks on Resident #10's hands was discontinued on 12/19/08, and restraints should not have been in use on the days this surveyor observed the socks on this resident's hands on 01/05/09 and 01/06/09. b) Resident #36 Review of Resident #36's medical record found a physician's order, dated 12/05/08, stating, ""Resident may have standard size lap buddy to be used to protect resident from injury to herself or others as a therapeutic enabler to maintain the resident's highest physical & mental well being. Will re-evaluate prn (as needed), not to exceed 90 days. Will monitor use of this enabler @ least q (every) 30 minutes & release, assess & provide needs q2hr / prn (every two hours as needed). Resident may be enabler free during meal time while supervised. Use of this enabler is secondary to unsteady gait secondary to dementia."" Further review of the medical record revealed that, on 12/05/08, a ""Physical Restraint / Enabler Assessment"" was completed. Documentation on this assessment stated the conditions and circumstances necessitating the use of the restraint were ""danger of harming self or others"", as well as ""to improve self functioning"" through promoting ""proper positioning"". Instructions on the section titled ""Restraining Device"" stated ""complete if device is a restraint to be used to enhance functioning""; this section was left blank, even though the section above stated the device was being used ""to improve self function"". The next section on the assessment was titled ""Enabler Device"", which was to be completed if the device were an enabler to enhance functionality. The assessor recorded ""poor safety awareness with frequent falls"" as the medical symptom to be treated by the use of the device. The assessor also recorded that the device was to be used when the resident was in the wheelchair. Another form in the medical record titled ""Physical Restraint / Enabler Information"" was reviewed. There was a separate form for various devices used for this resident. These forms described if the device was a physical restraint or an enabler and the potential benefits and risks. (A separate form was completed for the perimeter mattress, the mobility alarm to the bed, the mobility alarm to the wheelchair, the low bed, and the lap buddy.) The form completed for the lap buddy identified was the device as an enabler of which this resident was cognitively aware. Among the benefits for using this device, the assessor recorded reduce risk of falls and maintenance of proper body positioning. The form contained a section titled ""Potential risks of a physical restraint / enabler use may include:""; this section was left blank. Further review of the nursing notes and incident / accident reports revealed this resident did not want the lap buddy attached to her chair, and it caused increased agitation. An incident / accident report, dated 12/05/08 at 7:00 a.m., stated, ""Resident continually tries to get out of chair to bed or from bed to chair. Resident placed in chair, belt alarm on and checked, resident taken to area beside nurses station. Lap Buddy put on and seat belt alarm removed."" An incident / accident report, dated 12/06/08 at 7:00 a.m., stated, ""Res (resident) was pushing at lap buddy while CNA (certified nursing assistant) was trying to put it on her wheelchair and residents wrist band slid and cut her arm."" Further documentation on this report recorded the resident ""stated that she was mad over lap buddy and was trying to keep the CNA from putting it on the WC (wheelchair)"". Another incident / accident report, dated 12/11/08 at 11:30 a.m., stated, ""Res (resident) did not want lap buddy put back on after going to the restroom. She pushed on lap buddy, fighting against the CNA and she got a skin tear on R (right) forearm."" Documentation on this incident / accident report indicated the resident was not compliant with the use of the prescribed assistive device and she tried to remove the lap buddy. An incident / accident report, dated 12/21/08 at 10:00 a.m., stated Resident #36 ""reopened a ST (skin tear) to the L (left) arm. Resident was fighting against CNA who was putting lap buddy on WC. She was flailing her arms around and hit arm on wheelchair."" A nursing note, dated 12/21/08 at 4:30 p.m., recorded, ""Resident continues to kick and hit during the application of lap buddy. Will monitor use of new lap buddy."" A nursing note, dated 12/25/08 at 1:00 p.m., recorded, ""Resident loud and verbal this a.m. (morning) Has made several attempts at removing lap buddy from chair, becomes physically aggressive with staff during care. Continue to monitor."" A nursing note, dated 01/03/08 at 6:30 p.m., recorded, ""Res observed throwing water pitcher full of water onto floor of room. She had also pushed over the bedside table. Resident stated that she wanted her lap buddy removed. Will continue to monitor for adverse behavior."" An interdisciplinary progress note, dated 12/15/08, recorded a new medication was being used and stated, ""She is also not always compliant with wearing double geri-gloves. She will take the off and not let the staff place them."" There was nothing mentioned about the noncompliance with the lap buddy or the fact that this resident was resistant to its use and was injuring herself with this device, which was ordered for safety to prevent injury. The resident's physical restraint / enabler care plan, dated 12/05/08, did not contain a problem, goal, or interventions with respect to the use of the lap buddy to promote increased functioning; the care plan simply said, in the first section, ""Refer to the physical restraint / enabler assessment""; the associated goal was: ""Will be free of negative effects with the use of an enabler."" The interventions listed did not assist in achievement of the stated goal. The interventions were: apply the enabler (lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which was reviewed and did not refer to the lap buddy in any way or resisting its use); refer to the falls assessment prevention and management plan of care (which did include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy) prevention and management plan of care; maintain resident bowel and bladder routine; and educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was not complete). The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning, nor did it address the fact that the resident became agitated / resisted using this device and sustained injuries when the device was applied. During a dinner observation at 6:00 p.m. on 01/06/09 and a lunch observation at 12:30 p.m. on 01/07/09, this resident was observed sitting in her room eating independently with the lap buddy still attached to her wheelchair. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she stated this device was not a physical restraint; it was an enabler. When questioned about the difference between a physical restraint and an enabler, she indicated that, if a resident could not get up own his/her own, it was not a restraint. She was made aware of the inconsistent documentation and the inadequate assessment of this device for Resident #36. c) Resident #35 Record review revealed the following physician's order dated 12/19/08: ""Lap buddy may be used to protect resident to maintain residents highest physical / mental well being. Will reevaluate prn (as needed) not to exceed 90 days. Will monitor use of this restraint at least 30 minutes and release q 2 hours prn to assess and provide needs as needed. May be restraint free during meal time while supervised. Use secondary to dementia."" Further record review revealed a form titled ""Physical Restraint / Enabler Information"", dated 12/19/08, on which was written ""Lap Buddy"". Documentation on the form indicated the lap buddy was an enabler and the resident could remove it at will. The record contained another form titled ""Physical Restraint / Enabler Assessment. Documentation on this assessment form stated that the conditions for restraint consideration for this resident included ""danger of harming self or others"". Documentation at the bottom of the form indicated the device was an enabler to enhance functionality. According to this information, the enabler device was being used to treat the following medical symptom: ""Unable to ambulate independently secondary to [MEDICAL CONDITION]"". Review of the resident's current care plan, dated 12/05/08, found the statement: ""Refer to the physical restraint / enabler assessment."" The goal associated with this statement was: ""Will be free of negative effects with the use of an enabler."" The interventions were not pertinent to assist with the achievement of this goal. The interventions simply stated: ""Apply enabler, lap buddy, to wheelchair. Medical symptom: poor safety awareness secondary to dementia and [MEDICAL CONDITION]. Review the physical restraint / enabler sheet every 90 days."" The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning. The DON, when interviewed about the use of this lap buddy, verified that the use / purpose of this device was inconsistently documented, and she acknowledged it was ordered by the physician as a physical restraint but was treated by the facility as an enabler. d) Resident #28 Medical record review, conducted on 01/06/09 at 1:32 p.m., revealed Resident #28 had physician's orders for a pommel cushion and a lap buddy. Further review revealed both devices were identified as ""enablers"" to protect her from injury due to decreased safety awareness. Review of the facility document titled ""Physical Restraint / Enabler Information"" found the following difference between a physical restraint and an enabler: - ""A physical restraint is any manual or physical or mechanical device, material or equipment attached or adjacent to the resident body that cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body."" - ""An enabler is a device, material or a piece of equipment attached or adjacent to the residents' body that the resident can easily remove and is cognitively aware of."" The Centers for Medicare & Medicaid Services (CMS) state, ""Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."" On 01/06/09 at 5:30 p.m., the licensed practical nurse (LPN - Employee #36) identified that Resident #28 was not able to remove her lap buddy. Review of the resident's quarterly minimum data set assessment (MDS), dated [DATE], identified the resident's cognitive skills for daily decision making were moderately impaired. The use of the lap buddy with pommel cushion with Resident #28, therefore, did not meet the facility's own definition of an ""enabler"". Review of the facility policy titled ""5.2.1 Physical Restraint / Enabler Program"" revision date April 2006 identifies on page, in section 3-C: ""Select appropriate physical restraint alternative / enabler based on assessment. - Complete Restraining Device Section, if the device is a restraint used to enhance functionality. - Complete Enabler Device Section, if the device is an enabler used to enhance functionality."" Review of the document titled ""Physical Restraint / Enabler Assessment"" for the lap buddy (initially completed on 11/28/07 updated on 02/03/08, 05/14/08, and 11/19/08) found the assessor never identified the lap buddy as a physical restraint. Review of the resident's current care plan, dated 11/26/08, found staff identified the lap buddy as an enabler, although the device met the facility's definition of a physical restraint (not an enabler). The care plan did not contain a systematic and gradual plan towards reducing the use of the restraint (e.g., gradually increasing the time for ambulation and muscle strengthening activities), nor did the care plan identify what care and services would be provided during the periods of time when the restraint would be released or what meaningful activities would be provided. e) Resident #85 Record review revealed Resident #85 used a lap buddy daily, but there was no systematic plan for restraint reduction, release, and meaningful activities to be provided. There was also a discrepancy within the facility's documentation as to whether her lap buddy was a physical restraint or enabler. Documentation on the physical restraint information sheet, dated 4/15/08, noted the application of a lap buddy to her wheelchair and defined a physical restraint as a device that ""cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body"". The assessor consistently documented in Section P4 of the resident's MDS assessments, dated 06/26/08, 09/25/08, and 12/2508, that a ""trunk restraint"" was in use. During an interview on 01/08/09 at 11:15 a.m., Employee #18 said the MDS assessments were coded incorrectly, and the lap buddy should have been coded as a chair preventing rising, and agreed they should have one (1) care plan per device. Review of Resident #85's current care plan found the use of a physical restraint was initially developed on 04/15/08. The care plan did not specify interventions of a systematic plan for restraint reduction nor for planned releases of the lap buddy. The care plan also did not specify meaningful activities, rather it stated to ""See Activity Pursuit POC"" (plan of care). Review of the activity pursuit plan of care found interventions of large music groups, socials, parties, and visits with family, but there were no plans to offer diversional activities as a part of a restraint reduction plan to keep the resident engaged, so that a physical restraint may not be necessary. Interview with the activities director (Employee #11), on 01/08/09 at 2:00 p.m., revealed her belief that Resident #85 had declined a lot the past few months and no longer took part in many activities; she estimated the resident's attention span to be ten (10) minutes at the most. She said she did provide for Resident #85 one-on-one activities two (2) or three (3) times per week. She cited the resident's illness in September as the beginning of her decline and produced an activity record for August that evidenced much more participation in activities. Random observation on 01/07/09, between 11:15 a.m. and 11:30 a.m., found her up in the wheelchair with the lap buddy in place. During this time, she entered four (4) residents' rooms. Housekeeping staff brought her out once, a nursing assistant brought her out once, and she left on her own accord twice. Another random observation on 01/07/09, between 11:33 a.m. and 11:41 a.m., revealed she was up in the wheelchair with the lap buddy in place. Her daughter came in for a visit to feed her and to walk around the building with her, and she continued to have the lap buddy in place throughout the family visit until the daughter left at 1:30 p.m. She was returned to bed at 1:45 p.m. after being in the wheelchair with the lap buddy for at least two and one-half (2-1/2) hours. On 01/07/09 at 6:15 p.m., the DON stated a ""restraint is anything that restricts you from standing up"", citing if a resident could not stand up voluntarily anyway, then the device was an enabler (not a physical restraint). She stated that, if a resident were leaning or scooting out of a chair, then the lap buddy would also be an enabler; she replied in the affirmative when asked if a tied restraint would also be an enabler in that same situation. She said she believed an enabler was coded as a trunk restraint on the MDS. .",2014-02-01
11487,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,285,D,,,UFEY11,"Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. .",2014-02-01
11488,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,329,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation to reflect an assessment for [MEDICATION NAME] or extrinsic factors that may have caused or contributed to the increase in behaviors. On 10/01/08, she again exhibited increased behaviors, and she was given [MEDICATION NAME] 1 mg IM. The facility did not contact the psychiatrist regarding these events. A urinalysis later revealed Resident #62 had a urinary tract infection [MEDICAL CONDITION]. The facility failed to rule out [MEDICATION NAME] or extrinsic causes of the increased behaviors prior medicating her with [MEDICATION NAME] IM. 4. On 11/12/08, the attending physician added [MEDICATION NAME] ER to the resident's medication regimen. There was no evidence to reflect the facility contacted the psychiatrist regarding changes in the resident's behaviors / condition for which the attending physician added the [MEDICATION NAME] ER. 5. On 01/07/09 at 4:15 p.m., the director of nursing (DON - Employee #2) was questioned if psychiatric services was consulted upon increase in behaviors. On 01/08/09, the DON was unable to provide any information to show that the facility had contacted the resident's psychiatrist after any of the episodes which resulted in changes in her psychoactive medications. .",2014-02-01
11489,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,520,E,,,UFEY11,"Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). There was no evidence that the facility's QAA committee had been monitoring the effectiveness of the facility's infection control program. (See also citation at F441.) Quality deficiencies would have been evident had the QAA committee members reviewed the facility's infection incidence rate reports and/or infection surveillance worksheets, which were incomplete. .",2014-02-01
11490,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,225,D,,,UFEY11,"Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, ""the aids (sic) hurt her legs and were rough with her"". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There was also no evidence that this bruising of unknown origin was investigated or reported to the appropriate state agency. During an interview at 12 noon on 01/08/09, the DON stated she did not report the injuries. During an interview at 12:10 p.m. on 01/08/09, the administrator stated she would check into these injuries. She subsequently confirmed there was no accident / incident report and the injuries were not been reported to the State agencies. There was no formal investigation initiated to find the cause of the injuries. A ""late entry"" accident / incident report was shown to the surveyor at 1:30 p.m. on 01/08/09. .",2014-02-01
11491,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,313,D,,,UFEY11,"Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to ""see all the time"". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, ""I don't hear well."" After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, ""Resident noted to refuse to interact with staff members for brief period, ignored this nurse when asked to take medications. VS (vital signs) were WNL (within normal limits)."" The nurse then indicated that, when the nursing assistant addressed the resident, the resident responded cooperatively. During medical record review, the resident's hearing was reviewed. The admission assessment, dated 04/08/08, indicated the resident had hearing aids. The minimum data set (MDS) assessment indicated the resident did not have problems understanding others when a a hearing device was used. The care plan identified the resident was hard of hearing and contained an intervention - ""hearing aid clean"" . The care plan did not direct the caregiver to be sure the resident wore the hearing aids when she was up and/or to be sure that the hearing aids were working properly. A nursing assistant (Employee #63) was observed providing care for this resident at 12:30 p.m. on 01/08/09. She was asked if she had provided care to this resident in the past, and she said she had been here a while and had worked with this resident many times. When asked if she was aware the resident had hearing aids, she stated she was not aware of this and she had not seen them. At that time, Resident #36's roommate, from behind the privacy curtain, said, ""She has them in her drawer at her bedside."" The nursing assistant looked in the drawer and found two (2) hearing aids in a small case. The nursing assistant tried them and said that they must need batteries, because they were not working. The facility did not assure this resident's assistive hearing devices were clean, working properly, and placed in her ears so that she could communicate with and understand others. .",2014-02-01
11492,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,517,F,,,50Z111,". NFPA 101 Life Safety Code 2000 Edition Chapter 19 Existing Health Care Occupancies 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire - NFPA 99 Standard for Health Care Facilities 1999 Edition Chapter 11 Health Care Emergency Preparedness 11-2 Purpose. The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan. 11-4.2 Senior Management. It shall be the responsibility of the senior management to provide its staff with plans necessary to respond to a disaster or an emergency. Senior management shall appoint an emergency preparedness committee, as appropriate, with the authority for writing, implementing, exercising, and evaluating the emergency preparedness plan. This standard is not met as evidenced by: Based on review of the facility's disaster and emergency evacuation plan, the facility did not have a detailed written disaster and emergency evacuation plan. Facility census: 81. Findings include: a) On 10/06/10 at approximately 12:45 p.m., a review of the facility's disaster and emergency evacuation plan was conducted. At this time, the disaster and emergency evacuation plan did not contain a detailed plan for the safety of residents and staff in the event of a disaster and emergency evacuation. The facility's evacuation procedures addressed vertical and horizontal evacuation within the building and not the evacuation from the building, in the event a complete evacuation would be required.",2014-02-01
11493,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,456,F,,,50Z111,". Based on observation, staff interview, and measurements of ambient room air temperatures, the facility failed to maintain heating boilers in a safe operating condition. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. At the time of this interview, the administrator and maintenance director related a plan for the installation of a temporarily heating boiler for use during the winter until permanent repair / replacement of the existing heating boiler system could be implemented. This process would take approximately three (3) weeks, during which the facility had to solicit competitive bids for a temporary heating boiler before a contract could be awarded to a outside vendor for installation. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. - d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. (See also citations at F224 and F257.) .",2014-02-01
11494,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,257,F,,,50Z111,". Based on observation, staff interviews, measuring of ambient air temperatures, and information from the National Weather Service, the facility failed to maintain comfortable and safe temperatures (between 71 and 81 degrees Fahrenheit (F)) throughout the building to minimize the risk of hypothermia. Ambient air temperatures in occupied resident rooms, measured in the presence of facility staff, were found to be below 65 degrees F. This deficient practice presented the potential for more than minimal harm to all residents in the facility and constitutes a finding of substandard quality of care. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/05/10 between 5:30 a.m. and 6:35 a.m., were as follows: B333 - 71 degrees F; B331 - 65 degrees F; B329 - 62 degrees F; B327 - 62 degrees F; B325 - 66 degrees F; B323 - 67 degrees F; B321 - 72 degrees F; B317 - 70 degrees F; B315 - 68 degrees F; B313 - 69 degrees F; B311 - 62 degrees F; B309 - 59 degrees F; B310 - 60 degrees F; B324 - 67 degrees F; B326 - 66 degrees F; B328 - 64 degrees F; B330 - 63 degrees F; B332 - 63 degrees F; C315 - 63 degrees F; C314 - 67 degrees F; C313 - 69 degrees F; C312 - 73 degrees F; C311 - 65 degrees F, C307 - 71 degrees F; C306 - 64 degrees F; C305 - 66 degrees F; C304 - 70 degrees F, C303 - 68 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 67 degrees F, C308 - 66 degrees F; C309 - 67 degrees F; C310 - 68 degrees F; C316 - 61 degrees F, C317 - 68 degrees F; B129 - 63 degrees F; B127 - 62 degrees F; B125 - 68 degrees F, B123 - 67 degrees F; B121 - 66 degrees F; B119 - 68 degrees F; B117 - 72 degrees F, B113 - 73 degrees F; B122 - 64 degrees F; B124 - 63 degrees F; B126 - 61 degrees F, C115 - 65 degrees F; C114 - 61 degrees F; C113 - 65 degrees F; C112 - 67 degrees F, C111 - 65 degrees F; C107 - 69 degrees F; C106 - 61 degrees F; C105 - 67 degrees F, C104 - 68 degrees F; C103 - 64 degrees F; C101 - 66 degrees F; C100 - 62 degrees F, C102 - 65 degrees F; C108 - 68 degrees F; C109 - 64 degrees F; C110 - 65 degrees F, C116 - 66 degrees F; C117 - 58 degrees F. According to the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/06/10 between 8:30 a.m. to 9:15 a.m., were as follows: B331 - 66 degrees F; B325 - 62 degrees F; B323 - 69 degrees F; B321 - 69 degrees F; B315 - 67 degrees F; B313 - 67 degrees F; B311 - 61 degrees F; B310 - 65 degrees F; B324 - 68 degrees F; B328 - 64 degrees F; B330 - 61 degrees F; C314 - 61 degrees F; C313 - 69 degrees F; C312 - 67 degrees F; C311 - 64 degrees F; C307 - 63 degrees F; C306 - 63 degrees F; C305 - 57 degrees F; C303 - 67 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 68 degrees F; C309 - 65 degrees F; C310 - 66 degrees F; B127 - 62 degrees F; B125 - 67 degrees F; B123 - 68 degrees F; B119 - 69 degrees F; B117 - 70 degrees F; B113 - 68 degrees F; B122 - 62 degrees F; B124 - 64 degrees F; B126 - 59 degrees F; B128 - 61 degrees F; C114 - 62 degrees F; C112 - 71 degrees F; C107 - 65 degrees F; C106 - 63 degrees F; C105 - 64 degrees F; C103 - 68 degrees F; C101 - 67 degrees F; C100 - 62 degrees F; C102 - 66 degrees F; C108 - 68 degrees F; C109 - 67 degrees F; C110 - 71 degrees F; C116 - 60 degrees F; C117 - 66 degrees F. d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. .",2014-02-01
11495,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,224,K,,,50Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled ""Heating back up plan"", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled ""Hypothermia: A Cold Weather Risk for Older People"", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled ""Hypothermia"" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was ""red-tagged"" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled ""Heating back up plan"" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted in the ambient air temperatures in resident rooms falling to unacceptably low levels, placing sixteen (16) of eighty-one (81) facility residents in immediate jeopardy of injury or death from hypothermia or other cold-related complications. The NIH warns in their 01/15/09 newsletter: ""... Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" An article by the MFMER dated 06/09/09 and entitled ""Hypothermia"", states, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article identified risk factors associated with developing hypothermia to include age [AGE] years or older, mental impairment, certain medical conditions (e.g., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), severe arthritis, Parkinson ' s disease, spinal cord injuries, disorders that affect sensation in the extremities (including [MEDICAL CONDITION] in diabetics), dehydration, and any condition that limits activity or restrains the normal flow of blood), and the use of certain medications (e.g., antipsychotics). On 10/06/10 at 12:15 p.m., it was determined that residents had been sleeping in rooms with an ambient air temperature as low as 59 degrees Fahrenheit (F). Sixteen (16) facility residents, who were positive for one (1) or more risk factors for hypothermia and who had extended exposure to these unsafe temperatures, were determined to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F. The facility assessed these sixteen (16) residents as having body temperatures as low as 95.8 degrees F, placing them at risk for hypothermia. Information on hypothermia from CDC states: ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" The administrator was informed, at 12:15 p.m. on 10/06/10, that the facility's failure to provide a reliable source of heat to resident rooms placed more than an isolated number of residents in immediate jeopardy of injury or death, due to the potential for developing hypothermia. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve all occupied resident rooms, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. Upon removal of the immediate jeopardy, a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system without the use of portable electric space heaters. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Facility census: 81. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: ""... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" The CDC states, ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" An article by the MFMER titled ""Hypothermia"" (06/09/09) ( ) noted, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article also identifies the following risk factors associated with developing hypothermia: ""- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... ""- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... ""- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... ""- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature."" -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. .",2014-02-01
11496,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,493,K,,,50Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled ""Heating back up plan"", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled ""Hypothermia: A Cold Weather Risk for Older People"", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled ""Hypothermia"" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was ""red-tagged"" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timely manner resulted in findings of immediate jeopardy and substandard quality of care. It was determined, on 10/06/10 at 12:15 p.m., that residents residing in this unheated facility were placed in immediate jeopardy of harm or death related to the potential for developing hypothermia or other cold-related complications. Residents were found sleeping in rooms with ambient air temperatures as low as 59 degrees Fahrenheit (F). Sixteen (16) residents, who exhibited one (1) or more risk factors for developing hypothermia, were found to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F related to exposure to less than safe indoor temperatures. The governing body of this facility was ultimately responsible for the procurement, approval, and allocation of funding to maintain and ensure a safe and reliable heating system for this facility, as this entity alone possessed the authority to approve necessary repairs and/or replacement of this malfunctioning heating system. This practice affected sixteen (16) of eighty-one (81) residents currently residing in the facility. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: ""... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" The CDC states, ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" An article by the MFMER titled ""Hypothermia"" (06/09/09) ( ) noted, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article also identifies the following risk factors associated with developing hypothermia: ""- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... ""- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... ""- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... ""- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature."" -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. -- b) Review of facility documents found a request from the facility, dated 08/24/09, to replace a boiler which had been in operation since 10/94. The document from the governing body stated the funds were available and were awaiting ""your okay"". On 08/25/09, the chief operations officer (COO) of the governing body replied, ""I don't see anything happening with this project until next summer so we would need to be able to fire the old boiler one more winter..."" The facility replied, on 08/26/09, with, ""Yes sir, to be honest I was afraid that we were not going to make it last winter and we almost did not, this boiler blew tubes and went down at least ten times last winter, every time we blow a tube the steam fills the boiler and then is followed by the cold water supplying the boiler... I do not believe that this boiler will last through the winter if we were able to get all of this repair work completed before cold sets in, I honestly believe that at this point we need to try to get a new boiler just like this one and switch them out..."" As of the immediate jeopardy and substandard quality of care finding on 10/06/10, there was no indication the governing body had made any arrangements for the replacement of the boiler system, or the acquisition of an acceptable alternate heat source, to ensure residents were provided a safe and comfortable environment for the winter of 2010. .",2014-02-01
11497,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,323,D,,,50Z111,". Based on random observation and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as is possible. A nurse left a 50 cc bottle of liquid Dilantin on top of her medication cart, and left the cart parked and unsupervised at the unlocked nursing station. Resident #68 was observed to have unfettered access to the medication for approximately five (5) minutes. Facility census: 81. Findings include: a) Resident #68 Observations of the resident environment, on 10/06/10 at 8:08 p.m., noted Resident #68 wandering the resident hallway. She was observed to enter the unlocked nursing station and approach the medication cart parked there. No staff members were visible in the hallway or at the nursing station. The resident was approached and an attempt was made to redirect the resident's attention away from a bottle of medication sitting on top of the cart. The resident made inappropriate answers to questions but followed this surveyor out of the nursing station. After approximately five (5) minutes, a nurse was observed to exit a resident's room with a treatment cart. She was informed that Resident #68 was found unsupervised in the nursing station where a bottle of liquid medication was noted to be sitting on top of a medication cart. When asked what the medication was, the nurse (Employee #168) stated the bottle contained 50 cc of Dilantin 125/5ml. She stated she had not been given a key to the medication room to secure the medication. .",2014-02-01
11498,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-12-02,431,B,,,50Z112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, ""They rub it on me,"" while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, ""No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use..."".",2014-02-01
11395,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,281,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, staff interview, and review of the Criteria for Determining Scope of Practice for Licensed Nurses published by the State licensing boards for registered professional nurses and licensed practical nurses (LPNs), the facility failed to provide services that meet professional standards of quality, as evidenced by the facility allowing an unknown employee to obtain intravenous access through an improper access site. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report dated 07/28/10 revealed an unknown employee had obtained intravenous access through Resident #109's port-a-cath without a physician's orders [REDACTED]. Review of the nurses note revealed no documentation of the incident and no clarification of the physician's orders. Review of the physician's orders [REDACTED]."" Another hand-written entry, with no date, stating access port-a-cath times three (3) weeks after the following order: ""[MEDICATION NAME] HCl 1 gram Intravenous (IV) - Q12H Everyday, 0900 2100: 1 gram Q12 [MEDICAL CONDITION]."" An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 3:00 p.m., revealed the DON agreed that a port-a-cath should never be used as an intravenous access site without a physician's orders [REDACTED]. Review of the Criteria for Determining Scope of Practice for Licensed Nurses, revised in 2009, revealed a Scope of Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse. Review of the Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse revealed a guideline stating: ""Is there a written order from a licensed Physician, Physician's Assistant, or Advanced Practice Nurse or is there a signed written protocol? If No, report / defer to qualified individual."" Further review also revealed a guideline stating: ""Would a reasonable and prudent nurse perform the act? If No, report / defer to qualified individual."" .",2014-03-01
11396,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,309,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. .",2014-03-01
11397,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,441,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control policies / procedures, review of the daily census report, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, as evidenced by improper cohorting of a resident with Methicillin-resistant Staphylococcus aureus (MRSA) with a compromised resident. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #13. Facility census: 108. Findings include: a) Resident #13 Review of Resident #13's medical record revealed she had been cohorted in a room with Resident #82, who was positive for MRSA since 10/29/10. Review of the daily census report revealed Resident #13 was moved to another room on 11/01/10. Review of the physician's orders [REDACTED]. Resident #13 was receiving the following treatments: ""Cleanse left lower leg with soap and water. Apply [MEDICATION NAME] cream, [MEDICATION NAME], and netting 2x per day on 7-3 and 11-7. Check placement QS. - NS, DS Everyday."" and ""Cleanse right lower leg with soap and water. Apply [MEDICATION NAME], and netting 1 time per day 7-3. Check placement QS. - DS Everyday."" Review of the facility's infection control policies / procedures revealed a resident with MRSA ""may be placed with a 'low risk' individual. Low risk means that the resident would not be clinically compromised. Definition of non-compromised resident is one who does not have surgical or other wound / open area."" An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 1:20 p.m., revealed he did not feel that Resident #13 was ""low risk"",and he further stated the proper protocol would have been to place Resident #82 on contact precautions, remove Resident #13 from that room, and contact the physician.",2014-03-01
11398,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2010-11-23,333,D,,,D3L711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents were free of significant medication errors, when a resident's [MEDICATION NAME] (an anticoagulant) was not administered in accordance with physician's orders [REDACTED]. This was found for one (1) of six (6) records reviewed. Resident identifier: #99. Facility census: 128. Findings include: a) Resident #99 The medical record of Resident #99, when reviewed on 11/22/10 at 2:00 p.m., revealed this [AGE] year old woman had resided in the facility since 07/24/09 and was receiving [MEDICATION NAME] therapy for [MEDICAL CONDITION]. ([MEDICATION NAME] dosage is regulated based upon laboratory testing results designed to measure the blood clotting time and blood clotting factor.) Resident #99 was ordered a dosage of [MEDICATION NAME] for 1.5 mg by mouth every other day, alternating with [MEDICATION NAME] 3.0 mg by mouth every other day on 09/01/10. She was found to be stable on this dosage until lab results, dated 10/25/10, were elevated. A new order was written on 10/27/10, for [MEDICATION NAME] 3.0 mg by mouth on Day 1, then 1.5 mg by mouth on Days 2 and 3 on a repeating cycle, thus lowering the overall dosage. Documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/01/10, the monthly recapitulation (recap) of physician's orders [REDACTED]. Consequently, the [MEDICATION NAME] orders on the November 2010 MAR indicated [REDACTED]. The physician had ordered on [DATE] (when the dosage was lowered) that a repeat lab test be conducted in two (2) weeks, because of the elevated results observed on the 10/25/10 test. When the lab results were obtained on 11/10/10, they were still elevated, and the error was apparently recognized. The dosage was subsequently changed back to conform with the physician's orders [REDACTED]. The MAR for November 2010 confirmed Resident #99 received [MEDICATION NAME] per the 10/27/10 order on 11/10/10 through 11/30/10. The record revealed Resident #99 received the wrong dosage of the [MEDICATION NAME] for nine (9) days, with the potential for increased bleeding. - Interview with the facility's director of nursing (DON - Employee #17, on 11/23/10 at 11:20 p.m., confirmed the dosage of [MEDICATION NAME] administered to Resident #99 was incorrect for the first nine (9) days of November 2010. She indicated she would conduct further investigation and return to continue the discussion. On 11/23/10 at 11:27 a.m., the DON returned with a medication error report that had been completed by the facility on 11/10/10, confirming the conclusion reached during the initial record review. The medication error report stated Resident #99 received the incorrect dose for ""approx (sic) 9 days."" In response to the question ""Could the error have endangered the life or welfare of the patient?"" was checked ""yes"". Under ""Explain"" was written: ""Increased (arrow pointing up) bleeding risk.""",2014-03-01
11399,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,278,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. .",2014-03-01
11400,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,241,D,,,FRRZ11,"Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. .",2014-03-01
11401,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,279,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote ""I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day."" During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) and the MDS coordinator revealed this resident did not communicate well and would not be able to verbalize in this manner, and this statement and care plan did not accurately describe the resident's pain was not accurate. c) Resident #28 A review of the resident's medical record revealed [REDACTED]. A review of the resident's care plan revealed the hospice care plan was not integrated with the facility's care plan for the resident. .",2014-03-01
11402,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,309,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. .",2014-03-01
11403,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,441,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. .",2014-03-01
11404,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,225,D,,,FRRZ11,"Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, ""he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks."" The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, ""Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided."" The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. .",2014-03-01
11405,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2010-11-02,279,E,,,QWDA11,". Based on observation, record review, and staff interview, the facility did not develop care plans for six (6) of seven sampled residents to provide justification for the residents to sit in the facility hallways in front of the nursing station to eat their meals. Resident identifiers: #19, #6, #26, #46, #45, and #44. Facility census: 75. Findings include: a) Residents #19, #6, #26, #46, #45, and #44 Observations, on 11/01/10 beginning at 12:15 p.m., found the above-identified six (6) residents sitting in front of the nursing stations in the hallways eating their lunch. Some of the residents were able to eat without assistance, and others were being fed by the staff. Four (4) residents (#6, #26, #46, and #45) were observed on the South hall, and two (2) residents (#19 and #44) were observed on the North hall. An interview with the director of nursing (DON), on 11/01/10 at 12:15 p.m., revealed the residents wanted to eat in the hallway in front of each nursing station. She further stated that some of the residents were unable to make the decision to eat in the hallway and the legal representative requested that the resident eat in the hallway in front of the nursing station. The DON also stated all of these residents had a care plan identifying the reason for each resident eating meals in this location. A review of the care plans these residents found no mention of eating their meals in the hallways. .",2014-03-01
11406,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2010-11-02,309,D,,,QWDA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of seven (7) sampled residents did not receive the influenza vaccine in accordance with the legal representative's wish to decline the vaccine due to an allergy. Resident identifier: #19. Facility census: 75. Findings include: a) Resident #19 Record review revealed a facility consent form titled ""Vaccine Administration Authorization"", upon which was recorded either acceptance or refusal to receiving the influenza vaccine, indicated that Resident #19's legal representative declined administration of the influenza vaccine, because the resident was allergic to it. On 10/21/10 at approximately 6:30 a.m., a nurse administered the influenza vaccine to the resident contrary to the wishes of the legal representative. At 8:00 a.m. on 10/21/10, Resident #19 became unconscious and was transferred to the hospital and admitted . Review of hospital records for Resident #19 revealed, ""[AGE] year old female nursing home resident presented to the hospital after having two [MEDICAL CONDITION]. Patient had received [MEDICATION NAME] at the nursing home after getting the flu vaccine which she is allergic to. Patient had recently been taken off [MEDICATION NAME] which she was on for a number of years for agitation. Two weeks prior to having [MEDICAL CONDITION], [MEDICATION NAME] was discontinued abruptly and she was started on [MEDICATION NAME]. Patient was admitted and we restarted [MEDICATION NAME]."" The hospital obtained an electrocardiogram (EKG), serial cardiac enzymes, CT of the brain, electroencephalogram (EEG), a chest X-ray, and blood work, and all results were within normal limits. An interview with the assistant director of nursing (ADON - Employee #32), on 11/01/10 at 1:30 p.m., revealed she was called to Resident #19's room after the influenza vaccine was administered to the resident by mistake at approximately 6:30 a.m. on 10/21/10. She immediately told the nurse to call the physician to obtain an order for [REDACTED]. The family of the resident had told her the resident was not allergic to eggs but was allergic to a preservative that was in the influenza vaccine and that she could not have the vaccine. The ADON also described the procedure the facility completed before administering the influenza vaccine, which involved gathering all consent forms for the vaccine and reviewing any allergies [REDACTED]. On the morning of 10/21/10, the nurse and the staff development coordinator had assembled the consent forms. The nurse had not reviewed the physician orders [REDACTED]. An interview with the director of nursing (DON), on 11/01/10 at 2:00 p.m., revealed, the nurse who administered the influenza vaccine to Resident #19 was no longer working at the facility. She further stated the nurse had not looked at the authorization form that indicated the resident was not to receive the vaccine and the nurse did not review the resident's physician orders [REDACTED]. An interview with the current staff development coordinator (Employee # 82), on 11/02/10 at 10:30 a.m., revealed he and another nurse had gathered vaccine administration authorization forms and the nurse was going to give the vaccine to the residents. The former staff development had asked them if they had reviewed the physician orders [REDACTED]. The nurse told him she had not looked at the physician orders [REDACTED]. He further stated the nurse apparently had not looked at the authorization form, because the resident received the vaccine and the authorization form indicated a refusal for the vaccine. A telephone interview with the facility's medical director, on 11/02/10 at 10:30 a.m., revealed he was not certain why the resident had the two (2) [MEDICAL CONDITION] after the flu vaccine was administered. The physician further reported he had never seen an influenza vaccine cause [MEDICAL CONDITION].",2014-03-01
11407,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-11-11,244,E,,,VERC11,". Based on review of resident council meeting minutes and staff interview, the facility failed to act upon a grievance made during a resident council meeting. On 09/27/10, residents expressed concerns regarding call lights not being answered during the midnight shift on Unit 4. This concern was not addressed by facility personnel. This practice had the potential to affect twenty-six (26) of twenty-six (26) residents who resided on Unit 4. Facility census: 107. Findings include: a) Review of the facility's 09/27/10 resident council meeting minutes, on 11/11/10, revealed residents expressed a concern regarding call lights not being answered on the midnight shift on Unit 4. Further review of the minutes revealed no evidence this concern had been acted upon by facility personnel. On 11/11/10 at 1:00 p.m., the administrator (Employee #16) was asked to provide evidence this issue had been addressed by the facility. At 1:10 p.m., Employee #16 reported the concern had not been acted upon as required.",2014-03-01
11408,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,157,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused""). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Provide nebulizer treatments as ordered."" Review of the facility's policy titled ""Notification of Refused or Held Medications / Treatments"" (policy #F-005, dated 10/15/05) found under the heading procedure: ""A. When a medication / treatment cannot be administered as ordered, the prescriber must be notified."" In an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) confirmed that nursing staff should have notified the physician that this resident was refusing her inhalation treatments at times. .",2014-03-01
11409,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,225,D,,,50T311,". Based on review of information from a criminal background check, staff interview, and review of a 2004 newsletter issued by the Office of Health Facility Licensure and Certification (OHFLAC) to all Medicare / Medicaid nursing facilities, the facility failed to ensure a West Virginia State Police background check was completed prior to hire for one (1) of one (1) background checks reviewed. Employee #123, a certified nurse practitioner (CNP), had been employed at this facility since May 2010, and no criminal background check by the West Virginia State Police had been completed as required by OHFLAC. Employee identifier: #123. Facility census: 118. Findings include: a) Employee #123 During a complaint investigation conducted at the facility between 11/08/10 and 11/11/10, it was discovered the facility had employed Employee #123 as a CNP since May 2010. Review of Employee #123's personnel record revealed the pre-employment screening conducted on this individual did not include a criminal background check by the West Virginia State Police in an effort to uncover a personal history of criminal convictions that may indicate this individual was unsuited for employment in a nursing facility. In an interview on the afternoon of 11/09/10, the facility's administrator (Employee #53) confirmed a criminal background check had not been conducted through the West Virginia State Police prior to hiring Employee #123. Review of a newsletter (dated November 2004), which had been distributed by OHFLAC to all Medicare / Medicaid certified nursing facilities in West Virginia, revealed the following directive: ""... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. Individuals for whom criminal background investigations have been initiated may begin work at the facilities pending satisfactory outcomes of the checks. ..."" .",2014-03-01
11410,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,281,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of May 2002) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. .",2014-03-01
11411,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,309,G,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded ""OK"". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and ""looked at the resident, then turned around and left the room"", and one (1) of the nurses stated, ""I'm sending her out of here. I'm leaving at 7:00."" There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and ""eyes not reactive to light accommodation"". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, ""Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach."" The next consecutive entry, dated [DATE] at 5:10 p.m., stated, ""N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware."" Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, ""Resident vomited x 3 this shift. Will monitor."" This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, ""Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee."" This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, ""N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention."" This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, ""N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, ""QMI (name of mobile imaging company) on site; CXR (chest x-ray) done."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, ""MPOA notified of decline; wish (sic) to send to TMH (area hospital)."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, ""KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants."" The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, ""Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]."" This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of [DATE]) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was ""Respiratory Arrest""; other signs and symptoms included ""Decreased LOC"". In the narrative section on page 1 of 6 was recorded, ""Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..."" Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, ""Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending."" Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of "",[DATE]"") revealed the following: ""Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident."" ""Procedure - Action Steps ""1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) ""2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. ""3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. ""4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. ""5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) ""6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. ""7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions."" According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as ""nursing notes"") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of ""Change in Condition"" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, ""to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER."" The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being ""frail and alert oriented x 2"" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: ""blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed."" At the end of this progress note was written: ""Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable."" - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and ""the symptom started 7 days ago."" (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, ""The patient complained of malaise and lethargy but denied fever and chills"" and she ""denied cough"". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: ""Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication."" - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, ""(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation."" Under review of symptoms, the CNP recorded, ""The patient complained of lethargy but denied fever and chills"", ""patient denied difficulty swallowing, sore throat and headache"", ""patient denied sOB (sic) and cough"", and ""patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation"". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was ""CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)."" The CNP recorded the resident's vital signs as: ""blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed."" Under prescriptions, the CNP recorded: ""[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]."" Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: ""Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]."" - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: ""Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment."" - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: ""[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting."" and ""IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)."" The second sheet of orders contained one (1) set of entries as follows: ""IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2."" - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were ""too accustomed to picking up the phone and calling EMS"". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she ""went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS."" This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res",2014-03-01
11412,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,328,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for [REDACTED].) - 3. Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of May 2002) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. (See also citation at F281.) - 4. A CNP progress note dated 10/13/10 (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and ""the symptom started 7 days ago."" Under review of symptoms, the CNP recorded, ""The patient complained of malaise and lethargy but denied fever and chills"" and she ""denied cough"". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: ""Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication."" - A CNP progress note dated 10/14/10 (and electronically signed electronically at 11:59 a.m. the same day) revealed, under chief complaint, ""(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation."" Under review of symptoms, the CNP recorded, ""The patient complained of lethargy but denied fever and chills"", ""patient denied difficulty swallowing, sore throat and headache"", ""patient denied sOB (sic) and cough"", and ""patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation"". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was ""CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)."" The CNP recorded the resident's vital signs as: ""blood pressure at Left Arm while Sitting is 135/738 (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed."" Under prescriptions, the CNP recorded: ""[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on October 14, 2010 and end on October 18, 2010. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on October 14, 2010 and end on October 20, 2010."" Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: ""Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]."" - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on 10/14/10, with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on 10/14/10 (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated 10/14/10 was identified as having been an amendment to the earlier progress note at 1:57 p.m. on 10/14/10. This amendment, which was electronically signed by the CNP at 10:44 a.m. on 10/15/10, contained the exact same information as found on the earlier note for 10/14/10 under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: ""Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment."" .",2014-03-01
11413,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,514,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, ""Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach."" The next consecutive entry, dated [DATE] at 5:10 p.m., stated, ""N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware."" Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, ""Resident vomited x 3 this shift. Will monitor."" This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, ""Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee."" This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, ""N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention."" This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, ""N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, ""QMI (name of mobile imaging company) on site; CXR (chest x-ray) done."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, ""MPOA notified of decline; wish (sic) to send to TMH (area hospital)."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, ""KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants."" The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, ""Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]."" - According to the AHIMA LTC documentation guidelines: ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #119's health status in accordance with professional standards of practice. -- 2. Review of the closed medical record for Resident #119, who was transferred to the hospital on the evening of [DATE] and subsequently expired, found a nursing note, dated [DATE] at 3:27 p.m., which contained six (6) separate late entries describing events said to have occurred one (1) week earlier between 1:00 p.m. and 5:00 p.m. on [DATE]. - According to the ""as-worked"" nursing schedule provided at 3:30 p.m. on [DATE] by the director of nursing (DON - Employee #81), the author of the late entries recorded on [DATE] (a licensed practical nurse (LPN - Employee #19)) worked from 7:00 a.m. to 7:30 p.m. on [DATE]. During the 7:00 a.m. to 7:30 p.m. shift on [DATE], Employee #19 recorded entries at 4:-0 (exact time not legible), 5:25 p.m., 7:00 p.m., and 7:22 p.m.; Employee #19 worked in the facility again from 7:00 a.m. to 7:30 p.m. on [DATE], and from 7:00 a.m. to 7:30 p.m. on [DATE] and would have been available to record these late entries more timely than she did. - According to the AHIMA LTC documentation guidelines: ""5.3.2.1. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ... ""When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes."" The late entries recorded by Employee #19 were not entered into Resident #119's record as soon as possible (which would have been during the 7:00 a.m. to 7:30 p.m. shift on [DATE]. Instead, they were recorded seven (7) days after the resident expired. This significant delay in recording the late entries calls into question the reliability of their contents. -- 3. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on [DATE] following a prolonged hospital stay beginning on [DATE] during which she received treatment for acute [MEDICAL CONDITION] (ARF). Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. - Review of the [DATE] MAR found, for her only day present in the facility in September ([DATE]), she had an order to receive [MEDICATION NAME] inhalation treatments every six (6) hours (at regular intervals four (4) times a day). Review of the [DATE] MAR indicated [REDACTED]. - In an interview at 3:30 p.m. on [DATE], the DON reported the resident was to have received the inhalation treatments every four (4) hours and the physician orders [REDACTED]. - Review of a progress note dictated by the certified nurse practitioner (CNP), dated [DATE] and electronically signed at 2:39 p.m., found an entry stating to continue to nebulizer treatment for two (2) weeks and re-evaluate. Review of the physician orders [REDACTED]."" Further review of physician orders [REDACTED]. Based on the information available in the resident's closed record, it is unclear when one (1) or more transcription errors may have occurred - when the CNP recorded the handwritten order to continue the [MEDICATION NAME] treatments on [DATE] (at a frequency different from what was specified in the resident's hospital discharge order), or when the order was carried over from the [DATE] MAR indicated [REDACTED]",2014-03-01
11414,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2010-11-18,311,D,,,0ZJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used.",2014-03-01
11415,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,309,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who was no longer affiliated with the facility) and made an appointment to have her evaluated. - Record review revealed a nursing note, dated 04/28/10 at 5:30 p.m., which stated, ""... Resident C/O (complained of) sore tongue (sic) slightly red / inflamed. (Name of attending physician) notified (sic) new order [MEDICATION NAME] 10 mg x 2 weeks - resident notified."" On 04/29/10 at 1:00 a.m., a nurse wrote, ""... [MEDICATION NAME] cont(inued) for mouth soreness. No complaints at this time."" On 04/29/10 at 7:40 a.m., a nurse wrote, ""... [MEDICATION NAME] to begin this AM (morning) for sore mouth, tongue slightly red and irritated. ..."" On 04/29/10 at 4:00 p.m., a nurse wrote, ""... [MEDICATION NAME] cont /s (without) adverse effects noted r/t (related to) sore touth (sic), tongue - slightly red / irritated - denies any further C/O (complaints). ..."" On 04/30/10 at 8:00 a.m., a nurse wrote, ""... [MEDICATION NAME] cont /c (with) no adverse effects noted for sore mouth, tongue slightly red, irritated. Denies any C/O this AM. ..."" On 04/30/10 at 11:30 a.m., a nurse wrote, ""Dtr (daughter) made appt (appointment) today /c (name of outside physician) at 1:30 p - follow-up (sic). Facility to take."" On 04/30/10 at 3:00 p.m., a nurse wrote, ""Returned back from (name of outside physician). Dx (diagnosis): glossitis, mouth ulcers, possible candidias (sic). New orders OK per (name of facility's physician): (1) [MEDICATION NAME] xylocane (sic) 1 tablespoon swish, gargle, and swallow QID (four times a day) x 10 days. (2) [MEDICATION NAME] 150 mg qday (sic) (every day) x 3 days. (3) 2 cc B12 IM (intramuscular injection) in AM. (4) 80 mg [MEDICATION NAME] IM x 1. (5) [MEDICATION NAME] oral susp(ension) 1 tsp QID PO (by mouth) swish, gargle, and swallow x 10 days. Dtr notified. Cont to monitor."" This entry was followed by an addendum, dated 04/30/10, noting the discontinuation of the [MEDICATION NAME]. - The nursing entries from 04/28/10 until 04/30/10 only addressed the resident's irritated tongue and did not contain evidence of an assessment of the resident's oral cavity as a whole; there was no mention of the presence of mouth ulcers which had been identified by the outside physician on the afternoon of 04/30/10. - In an interview on 11/16/10 at 8:45 a.m., the director of nursing (DON - Employee #88) reported the nurses had assessed the resident's mouth and only found that the resident had an irritated tongue. A nurse called the facility's physician and told him about the irritated tongue, and he ordered [MEDICATION NAME]. The DON provided, as evidence of assessment of the resident's oral cavity, a nursing assessment form (which include an oral / nutritional assessment) dated 02/27/10. However, this nursing assessment was completed two (2) month before the resident was diagnosed by the outside physician as having a glossitis, mouth ulcers, and possible candidiasis, for which he ordered treatment with five (5) medications. The DON further stated the facility's physician was in and visited the resident on 04/26/10, and there was no evidence the resident had complained about a sore mouth at that time. - A review of the physician's progress notes found an entry, dated 04/26/10, which did not indicate the resident had complained of a sore mouth. This physician visit, however, occurred two (2) days prior to the resident's first complaint of a sore mouth on 04/28/10. - A review of the monthly summary completed, by a licensed nurse on 04/05/10, revealed a section titled ""16. Oral Hygiene"". Within this section was ""Condition of Mouth"" followed by a space where a description of findings could be recorded; this space was left blank. - Review of nursing notes entered in the medical record after the resident returned from her outpatient physician visit on the afternoon of 04/30/10 with orders to treat found references to the resident's complaints of mouth pain or discomfort in entries made at 4:00 p.m. on 05/01/10, at 6:20 a.m. on 05/02/10, at 9:50 a.m. on 05/02/10, and at 4:00 p.m. on 05/02/10. However, there were no entries describing the physical condition of the resident's oral cavity until 10:00 p.m. on 05/03/10, when a nurse wrote: ""... Cont to have observable mouth ulcerations /c C/O discomfort..."" - Resident #153's daughter, after hearing complaints of oral pain and soreness from the resident and after hearing a report by her brother of the presence of sores in her mother's mouth, reported having asked facility staff to have the attending physician evaluate her. The facility failed to provide a full assessment, either by a registered nurse or the physician, of the resident's oral cavity after the resident complained of pain and soreness to her mouth. The resident's daughter was required to intervene and schedule an appointment with an outside physician in order to obtain appropriate treatment for [REDACTED]. -- b) Resident #73 During the observation of the passing of medications at 9:00 a.m. on 11/10/10, the licensed practical nurse (LPN - Employee #13) failed to administer [MEDICATION NAME] 25 mg which was ordered to be given at that time to Resident #73. The nurse surveyor compared the list of medications verbally told to her by the LPN during the medication pass (and observed being given to the resident) with the physician's orders [REDACTED]. Employee #13 continued on with her medication pass to the remaining residents on the B hall. During an interview with Employee #13 at 9:50 a.m. on 11/10/10, after she had completed the pass, she acknowledged she had not administered the [MEDICATION NAME]. She reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A comparison of the medications in the medication cart labeled for use by Resident #73 with the resident's MAR indicated [REDACTED] .",2014-03-01
11416,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,315,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of ""very cloudy and dark"" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with the presence of an indwelling urinary catheter, and she had NOT been diagnosed with [REDACTED]. -- According to her care plan dated [DATE] through [DATE], the interdisciplinary team identified the following problem: ""Risk for infection R/T (related to) indwelling foley (sic) cath (sic) and hx (history) of uti (sic)."" The goal associated with this problem statement was: ""Resident will exhibit no s/sx (signs / symptoms) of UTI thru next review aeb (as evidenced by) afebrile, no change in sedimentation of urine."" The interventions intended to assistant the resident in achieving this goal included: ""#16F foley (sic) with 30cc balloon per orders, Change Q (every) 4 weeks and prn (as needed). change (sic) urinary drainage bag Q 4 weeks and prn. Foley cath care Q shift. Provide incontinence cares (sic) frequently as able ensuring proper peri care due to increased risk of ecoli (sic) infection. Encourage and assist with fluids with and between meals for preventative measures. Monitor for s/sx of UTI such as hematuria (blood in urine), dysuria (painful urination), pyuria (pus in urine), abdominal pain, temp (sic), increasd (sic) confusion, etc. Notify MD as needed. hx (sic) of vre ([MEDICATION NAME]-resistant [MEDICATION NAME]). Monitor for s/s of uti (sic) during periods of increased blood sugars. Notify md (sic) of findings."" -- A nursing note, dated [DATE] at 12:30 a.m., revealed, ""Temp (temperature) 100.2 (symbol for 'oral') ... Urine very cloudy and dark. New order (sic) UA (urinalysis) & C&S (culture and sensitivity) this AM (morning) ...."" A nursing note, dated [DATE] at 11:15 p.m., stated, ""Labs returned. Abnormal UA - pH 9.0, Protein 75, Blood 250, Leukocyte Est 500 preliminary (sic) awaiting final."" (The normal ranges for these labs are: pH = 4XXX,[DATE].0, Protein = negative (0), Blood = negative (0), and Leukocyte Est = negative (0).) The next consecutive entry in the nursing notes, dated [DATE] at 12:20 a.m., stated, ""Temp 97.6 (Ax) (axillary). Foley catheter draining cloudy dark yellow."" The next consecutive entry, dated [DATE] at 11:00 a.m., stated, "" ... yells / moans @ (at) times (sic) complaints generally nonspecific and cease /c (with) conversation. T (temperature) 99.0 (symbol for 'oral') awaiting final C&S of UA. foley (sic) cath patent (sic) draining tea colored urine. denies (sic) abd(ominal) pain upon palpation. C/O (complains of) bladder feeling full (sic) abd small & soft. ... fluids (sic) encouraged by staff as well as ice chips ... will continue to monitor."" The next consecutive entry, dated [DATE] at 4:00 p.m., stated, ""Temp 98.6 (Ax). ... Yells / moans out occas (occasionally) /c C/O mouth pain. ... ice chips & fluids encouraged. foley (sic) cath patent draining dark tea colored urine - slightly blood tinged. Awaiting C&S of UA. ..."" The next three (3) consecutive entries in the nursing notes (dated [DATE] at 6:20 a.m., [DATE] at 9:50 a.m., and [DATE] at 4:00 p.m.) contained no mention of the status or characteristics of the resident's urinary output. The next entry, dated [DATE] at 2:10 a.m., stated, "" ... Indwelling foley (sic) drng (draining) small - mod amts of dk sl amber urine. ..."" The next consecutive entry in the nursing notes, dated [DATE] at 10:00 a.m., stated, ""Temp 99.6 (Ax). Lethargic. C/O not feeling well (sic) not wanting to be bothered."" An addendum following this entry stated, ""10 am. Received napoxen (sic) ([MEDICATION NAME] - a non-steroidal anti-[MEDICAL CONDITION] drug) @ 7:45 a.m. Will cont to monitor for S/Sx fever; infection."" The next consecutive entry, dated [DATE] at 11:00 a.m., stated, ""Up to BSC (bedside commode) (sic) became very weak, pale. Put back to bed. BP (blood pressure) ,[DATE]. P (pulse) 84. Skin cool (sic) clammy. After stimulation BP ,[DATE] P 82. Had expelled hard BM (bowel movement) prior to episode."" The next consecutive entry, dated [DATE] at 11:30 a.m., stated, ""Yelling (sic) insisting to be back up on BSC. ..."" This was followed by an entry by the same author with the same date and time, noting that a dose of [MEDICATION NAME] was withheld related to a possible adverse effect. The next consecutive entry, dated [DATE] at 10:00 p.m., stated, "" ... also C/O feeling very weak - orders rec (received) for lab wk (work) in AM (morning). Res (resident) made aware."" The next consecutive entry, dated [DATE] at 4:00 a.m., stated, ""Resting quietly in bed - awakens easily (sic) appears sl (slightly) listless. ... Ate 0% of meals [DATE] /c only (approx) 300 ml of fluids /c meals ..."" The next consecutive entry, dated [DATE] at 5:00 a.m., noted the arrival of the vendor laboratory service to collect specimens for blood work. The next consecutive entry, dated [DATE] at 10:00 a.m., stated, ""Lethargic. BS (blood sugar) elevated. BP low. Consulted Dr. (name of attending physician) /c exam. New order. Novalog ,[DATE] 10 units bid (twice daily). IV (intravenous fluids) 0.45% NaCl @ 100 cc/hr x 2 hours then 80 cc/hr. Transfer to (name of hospital) ER for eval."" The next four (4) entries in the nursing notes recorded the successful insertion of the IV, notification of the resident's change in condition and transfer to the resident's legal representative, transfer of the resident to the hospital, and mailing of the notice of transfer and bedhold policy to the resident's legal representative. -- The above nursing notes recorded evidence of the resident exhibiting signs and symptoms of a UTI beginning on [DATE] (e.g., dark, cloudy urine; blood in urine; low grade temperature; lethargy). These signs and symptoms continued without treatment or physician intervention from [DATE] until [DATE], when the resident was transferred to the hospital. -- Review of a lab specimen inquiry dated [DATE] with a run time of 1146 (11:46 a.m.) revealed the following abnormal results of the blood work collected in the early morning hours of [DATE]: - Glucose - 354 (normal range ,[DATE]) - Blood urea nitrogen (BUN) - 194 (normal range ,[DATE]) Below this lab value on the report was typed, ""Tried to notify Sunbrige (sic) of results - could not get pick-up on floor. Notified (name) (front desk) that I would be faxing results to floor. ..."" - Creatinine - 5.1 (normal range 0XXX,[DATE].3) - B/C (BUN / Creatinine) Ratio - 38 (normal range ,[DATE]) - Potassium - 5.1 (normal range 3XXX,[DATE].5) -- Lab results after Resident #153 arrived at the hospital revealed the following: - Urine specimen collected on [DATE] (with results dated [DATE]) - the appearance was noted to be ""turbid (cloudy) specimen red"" with ""large"" amount of blood, equal to or greater than 300 mg/dl of protein in the urine, with a quantity of red blood cells in the urine ""too numerous to count"" and ""loaded"" with bacteria. - Blood specimen collected on [DATE] (with results dated [DATE]) - cultured positive for [DIAGNOSES REDACTED] pneumoniae and Streptococcus mitis group. The resident was septic and subsequently expired at the hospital on [DATE]. -- An interview with the director of nursing (DON - Employee #88), on [DATE] at 8:45 a.m., revealed the resident's attending physician would always wait until the final lab report was received to determine what antibiotic to order. She further stated the physician would treat if a resident were symptomatic, but according to the DON, Resident #153 only had an elevated temperature on [DATE] and was not symptomatic of a UTI. -- Resident #153 was exhibiting signs and symptoms of a UTI beginning on [DATE] and continuing to [DATE], when the resident was transferred to the hospital. There was no evidence to reflect staff notified the attending physician of the resident's dark, cloudy urine, the presence of blood in the resident's urine, the resident's moaning and yelling, her lethargy, and/or of the overall change in the resident's condition prior to [DATE]. .",2014-03-01
11417,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,323,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: ""Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage."" The goal associated with this problem statement, with a target date of 08/18/10, was: ""Will have no injury r/t falls thru next review."" Interventions to achieve this goal included: ""up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders."" Review of her physician orders [REDACTED]."" -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, ""Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..."" -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. A hospital operation summary, dated 08/19/10, stated, ""The patient is a [AGE] year-old female who is known to me. Approximately a year ago, she sustained an intertrochanteric hip fracture while getting out of bed. ... She was admitted to an outside hospital and found to have a subtrochanteric femur fracture as above. She is extremely and morbidly obese. She does not really ambulate and has not ambulated for some time because of this. ..."" -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" In a statement dated 08/15/10 at ""12:15 about"" (per the author of the statement), Employee #22 (a nursing assistant) wrote: ""I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)."" In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: ""CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived."" In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: ""Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval."" In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: ""On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..."" There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. (See also citation at F225.) -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, ""The resident sustained [REDACTED]."" -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resides in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She also stated, ""I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling."" -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, ""The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor."" -- A review of the ""Owner's Operating and Maintenance"" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the ""sit-to-stand lift"") revealed a ""Safety Summary"" on pages 4 and 5, which included the following in a box labeled ""Warning"": ""DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. ""Individuals that use the Standing Sling (Model R130) MUST be able to support the majority of their own weight, otherwise injury can occur. ..."" In the section titled ""Transferring From"" on page 10, under the heading ""Lifting the Patient (Figure 1)"" were the following instruction to be performed before raising a resident above the surface being transferred from: ""F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place."" In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the ""maximum open position"") during the transfer of Resident #54, contrary to the manufacturer's instructions. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, ""When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand."" She further stated, ""We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position."" Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. .",2014-03-01
11418,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,520,E,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility census: 98. Findings include: a) Review of facility abuse / neglect self-reporting to State officials, on 11/11/10 at 9:30 a.m., revealed an incident that took place on 08/15/10 and was reported to the Office of Health Facility Licensure and Certification (OHFLAC, the State survey and certification agency) as an ""unusual occurrence"". Resident #54 sustained a fracture during an attempted transfer using a sit-to-stand lift. Documentation on the ""Immediate Fax Reporting of Allegations"" form, in the section headed ""Brief description of the incident"", stated: ""Called to resident's room by staff. Resident holding on to bar of sit to stand (sic) with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor and squad called to take resident to ER (emergency room ) for eval."" This form was signed by a registered nurse (RN - Employee #135). - The ""Five-day Follow-up"" form was completed on 08/18/10 by the facility's social worker (Employee #142). Documentation in the section headed ""Outcome / Results of Investigation"" stated: ""Unusual occurrence - resident slid during attempted transfer. No indication that maltreatment occurred. Resident stated that she let go of handle bar of lift (sit to stand)."" There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. - Two (2) written statements were included with the facility's reports from the nursing assistants who had been attempting the transfer. In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" - Review of all documentation associated with the facility's internal investigation found it was unclear how Resident #54 ended up on the floor. Employee #92 stated, ""She then let go with the other hand and slid down to the floor."" The description by the RN (Employee #135) stated, ""Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor ... "" There was no evidence of any investigation into statements by staff members of problems with using the sit-to-stand lift when transferring residents into and out of an electric bed, which apparently contributed to the resident's fall. -- b) A review of facility incident / accident reports, on 11/15/10 at 10:30 a.m., revealed an incident report for Resident #54 categorized as a fall, which documented the incident of 08/15/10 at 12:45 p.m. Documentation in the section headed ""Describe the circumstances of the event and what actions, if any have been taken currently"" stated, ""Called to resident's room by staff. Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident was lowered to floor. Unable to move by staff and and squad was called to assist resident. 4 squad members and 2 RN, 1 LPN, 2 CNA (certified nursing assistants) assisted resident on back board and stretcher, support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated 'I am not in w/c (wheelchair) right.' Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor, unable to obtain VS (vital signs) D/T (due to) positioning."" Documentation in the section headed ""Recommendations to prevent further falls"" stated: ""Use mechanical lift for transfers."" A hand written statement was attached to the report, composed by an RN (#111) and dated 08/16/10. It stated: ""(Name of Employee #92), (name of Employee #134), and (name of Employee #81) were re-educated on the sit to stand lift following the (name of Resident #54) fall (sic) RMS (Risk Management System) # 1."" There was no apparent investigation of the problem of using a sit-to-stand lift in conjunction with an electric bed. There was no reason given why it was recommended that a mechanical lift should be used with Resident #54 after the fall, instead of the sit-to-stand lift. There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. There was no explanation as to why it was necessary to provide re-education to only these three (3) employees (if nothing had been done improperly); if any re-education were felt to be warranted, there was no explanation as to why this re-education was not then provided to all staff that might use the sit-to-stand lift. -- c) Record review revealed Resident #54 was a [AGE] year old female who was 5' 1"" tall and weighed between 280# and 301# during her residency in this facility; at the time of this survey event, Resident #54 resided in another facility. Resident #54 was interviewed via telephone at 9:55 a.m. on 11/16/10. She was asked about the incident of 08/15/10, which she said she recalled clearly. She stated that, when she was being moved in the lift, the lift tipped or lurched, causing her ""to go over"". She also reported her belief that the lift was broken at the time is was being used. -- d) During an interview with the director of nursing (DON - Employee #88) on 11/16/10 at 11:00 a.m., she stated there were some beds in the facility with which the sit-to-stand lift could not be used. She said the sit-to-stand lift could not be used with the electric beds, because the legs of the lift could not be fully opened when they were under the bed. She demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. -- e) The manufacturer's operating manual for the sit-to-stand lift was reviewed at 10:00 a.m. on 11/16/10. In the section headed ""Lifting the patient"", was Step F, which stated: ""Make sure the legs are in the maximum open position and the shifter handle is locked in place."" -- f) An interview was conducted, on 11/16/10 at 10:29 a.m., with the two (2) nursing assistants involved in the above-referenced event (Employees #92 and #134). They both stated that the legs of the sit-to-stand lift were not in the open position when they lifted Resident #54 from the bed and attempted to transfer her to the wheelchair and back. -- g) The facility's administrator (Employee #28), when interviewed on 11/15/10 at 2:30 p.m., was asked if the facility's QAA committee had topics that were always placed on the agenda for discussion by the committee members. He related there were items looked at in every meeting, which included past survey results, customer base, incidents / accidents, abuse / neglect reporting, medication errors, and department-specific topics related to their operations. Discrepancies found by the surveyor during an investigation into the events of 08/15/10, which included a review of written statements obtained by the facility from individual staff members, information obtained by the surveyor through interviews with staff members and a telephone interview with Resident #54, and a review of facility documentation, identified concerns related to the use by staff of the sit-to-stand lift during Resident #54's transfer resulting in a [MEDICAL CONDITION]. These discrepancies were discussed with the administrator, who was asked to provide to the surveyor any additional documentation not previously produced, to demonstrate the circumstances of Resident #54's transfer and fall were reviewed by facility management and/or the QAA committee and steps were taken to ensure no other residents were injured in the future during the use of the sit-to-stand lift. He voiced understanding and stated he had spoken with Resident #54 following the events of 08/15/10, and that she had not said anything to him about the lift tipping or lurching. He stated he had notes of this conversation. He subsequently provided: (1) a ""Customer First Ambassador Rounds Worksheet"", which he stated was the discussion with the resident when she returned from the hospital; (2) the facility's incident report of 08/15/10; and (3) a policy entitled ""Resident / Patient Lifting / Transfer"". - Upon review of Resident #54's ""Customer First Ambassador Rounds Worksheet"", this form consisted of observations and interviews conducted by the social worker (Employee #142) on 08/25/10, 08/26/10, 08/27/10, 09/13/10, 09/15/10, and 09/17/10. The interview questions were general satisfaction items, such as ""Was the food appetizing in taste?"", ""Has the housekeeping staff kept you room to your satisfaction?"", ""Has the staff been taking good care of you?"" The observations were also general in nature, covering areas such as hygiene and grooming, environment, and water pitchers. There was nothing found that addressed the incident of 08/15/10. - Review of the facility incident report provided by the administrator found that additional pages were attached, to include a cover sheet containing the signatures of the administrator and the DON, indicating they had reviewed the investigation of the incident. - Review of the facility's ""Resident / Patient Lifting / Transfer"" policy found it covered all aspects of lifting and transfer. The only specific mention of the sit-to-stand lift was under Section 4 for ""Equipment"", which stated: ""Sit to-Stand Lifts - designed to assist the caregiver in standing a resident / patient up, without the need for any manual lifting. The resident / patient only needs minimal weight bearing ability to be transferred easily from bed to toilet or chair."" There were no specific policies or procedures presented regarding appropriate use and safe operation of the sit-to-stand lift. There was no documented training or education provided to address whether the sit-to-stand lift should not be used with some beds (e.g., electric) or that the legs of the lift must be fully opened before lifting a resident.",2014-03-01
11419,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,225,D,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to conduct a thorough investigation, and make a report to the Nurse Aide Registry of two (2) nursing assistants, of neglect involving one (1) of eighteen (18) sampled residents who was injured during an unsafe transfer. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The facility's internal investigation into this fall was not thorough as evidenced by a failure to conduct an interview with the affected resident, who was alert and oriented and available for interview upon her return from the hospital to the facility; when interviewed by a surveyor, the resident related information markedly different from what had been reported by staff involved in the incident. The facility also failed to identify during its investigation that the sit-to-stand lift was not used in accordance with the manufacturer's instructions. The two (2) nursing assistants who were involved in the transfer failed to ensure the legs of the sit-to-stand lift were in the maximum open position for stability prior to attempting to transfer the resident. The facility did not identify this as neglect and/or report the individuals involved to the appropriate State agencies as required. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: ""Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage."" The goal associated with this problem statement, with a target date of 08/18/10, was: ""Will have no injury r/t falls thru next review."" Interventions to achieve this goal included: ""up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders."" Review of her physician orders [REDACTED]."" -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, ""Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..."" -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" In a statement dated 08/15/10 at ""12:15 about"" (per the author of the statement), Employee #22 (a nursing assistant) wrote: ""I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)."" In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: ""CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived."" In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: ""Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval."" In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: ""On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..."" There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, ""The resident sustained [REDACTED]."" -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. He believed the staff involved was not negligent during the transfer, and he verified the two (2) nursing assistants were not reported to the Nurse Aide Registry. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resided in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She stated, ""I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling."" -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, ""The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor."" -- A review of the ""Owner's Operating and Maintenance"" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the ""sit-to-stand lift"") revealed, in the section titled ""Transferring From"" on page 10, under the heading ""Lifting the Patient (Figure 1)"", the following instruction to be performed before raising a resident above the surface being transferred from: ""F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place."" In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the ""maximum open position"") during the transfer of Resident #54. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, ""When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand."" She further stated, ""We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position."" Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. .",2014-03-01
11420,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,242,E,,,U2Q611,". Based on staff interview and record review, the facility failed to identify and communicate to direct caregivers the residents' preferences with respect to what time of day they were to receive showers. This was evident for at least seventeen (17) of twenty-two (22) residents who routinely received showers during the night shift. Resident identifiers: #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Facility census: 150. Findings include: a) Residents #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Interviews with nursing staff working night shift on 10/24/10 and 10/25/10 revealed residents were being given showers and baths during this shift. A review of shower documentation sheets revealed residents were scheduled and listed as having been given a shower or bath at various times throughout the night shift. Staff stated, in confidential interviews, they showered or bathed anywhere from one (1) to three (3) residents this shift each day except Sunday. There was no evidence, via record review, to reflect the facility staff made efforts to ascertain whether the practice of bathing during the hours of night shift was either a personal preference or customary routine of the residents or whether the practice was acceptable to the residents, as it may require awakening sleeping residents to perform this task. Review of care plans for these residents, on the morning of 11/02/10, found the care plans addressed the need for assistance with bathing, but they did not indicate what time of day each resident preferred to bath or shower. Interview with the administrator, on the morning of 11/02/10, again revealed there was no evidence that permission had been obtained from each of these residents or responsible parties to provide showers or baths to the residents during the night shift. .",2014-03-01
11421,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,279,E,,,U2Q612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. Resident identifiers: #150 and #151. Facility census: 142. Findings include: a) Resident #150 Review of Resident #150's medical record found a nursing note, written at 3:20 a.m. on 11/27/10, documenting the resident was sent to the emergency room for rectal bleeding with clots. He returned to the facility on [DATE]. Review of the current care plan, on 01/06/11, found no care plan for monitoring and assessment for gastrointestinal (GI) bleeding. An interview with the DON, on 01/06/11 at 11:40 a.m., confirmed the potential for GI bleeding should have been included in the comprehensive care plan. -- b) Resident #151 Review of the medical record found that Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the current care plan, on 01/06/11 at 4:35 p.m., confirmed the care plan did not include interventions for [MEDICAL CONDITION] precautions. .",2014-03-01
11422,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,425,E,,,U2Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on review of medical records, review of reports from the facility's provider pharmacy and consultant pharmacists, staff interviews, review of the facility's pharmacy policy and procedure for adverse drug reactions, review of a list of drugs with the potential to interact with Coumadin, and the manufacturer's sheet for Coumadin, it was determined the facility had not implemented pharmaceutical services procedures to minimize medication-related adverse consequences or events. One (1) resident who was receiving Coumadin was ordered Bactrim DS for an infection. The resident fell and was later hospitalized . She was found to have subarachnoid bleeding. The hospital physician identified this may have occurred due to the resident receiving Bactrim DS and warfarin (Coumadin). The records of thirty (30) residents who were receiving warfarin were reviewed. Thirteen (13) were found to have orders for medications known to have major interactions with warfarin (a blood thinner). There was no evidence the potential for interactions had been identified by the pharmacists. Additionally, the facility's pharmacy manual included a policy which included notification when there was a potential adverse drug reaction (ADR). There was no evidence this policy had been implemented for residents receiving warfarin. Resident identifiers: #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131. Facility census: 150. Findings include: a) Residents #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131 A review of residents receiving the medication warfarin was prompted by a complaint allegation. On the morning of 10/26/10, a request was made for copies of the physicians' orders for residents who were receiving warfarin. A copy of the facility's policy for adverse drug reactions was also requested. Copies of the orders for thirty (30) residents were provided the afternoon of 10/26/10. The ordered medications were compared to the lists of drugs with a potential to interact with warfarin identified on the manufacturer's drug insert. These were further reviewed via the Internet at Drugs.com. Thirteen (13) of the thirty (30) residents were found to have one (1) or more drugs listed as having the potential to have major interactions with warfarin. All thirty (30) residents were receiving medications that had a potential to interact with warfarin, ranging from minor to moderate to major. For example: 1. Resident #29 This resident had an order for [REDACTED]. She was also receiving Gemfibrozil twice a day for [DIAGNOSES REDACTED]. This medication was listed on the manufacturer's package insert as having the potential, alone or in combination, to increase PT/INR response. According to the information found at Drugs.com, this medication was known to have the potential for a major interaction with warfarin. Bactrim DS, an antibiotic, was added to the resident's medication regimen on 10/10/10 and first administered on 10/11/10. According to information found in the manufacturer's package insert and Drugs.com, this medication also had a known potential to increase the PT/INR. 2. Resident #52 This resident was also receiving warfarin. Her other medications and potential interactions included: Fenofibrate - major Fluconazole - major Lovenox - major Cymbalta - minor Levothyroxine - moderate Omeprazole - moderate Ropinirole - moderate (She had been readmitted from the hospital on [DATE]) 3. Resident #137 The resident was receiving warfarin. Ciprofloxacin was ordered for twice a day for ten (10) days on 10/19/10. Ciprofloxacin is listed as having a major potential for interacting with warfarin. - b) The facility provided a copy of a policy / procedure regarding adverse drug reactions (ADR) as requested. This included: ""Warfarin Interactions a) Determine if the drug interaction potential is serious and predict the timing of the interaction effect as advised by FDB (First Data Bank) . b) Recommend an alternate medication if possible (i.e. azithromycin instead of erythromycin or clarithromycin) or determine if a warfarin dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention on Policy Form #038.3A and record any order or INR monitoring changes at the bottom as directed by the physician. c) If the interaction is NOT immediate or serious the dispensing pharmacist documents their review and assessment by overriding the hang-up in the computer and printing the FDB drug interaction sheet. d) The FDB drug interaction sheet is sent with the medication delivery or faxed to the facility. . . ."" Random review of the residents receiving warfarin did not find any evidence of such notifications. The director of nursing was asked for copies of pharmacy recommendations the facility had received. She stated she had them back to May 2010. Approximately one hundred-forty (140) documents from the pharmacy to the facility were reviewed. The majority of these were regarding medication interchanges or need for hand written prescriptions for controlled substances. Only one (1) document addressing the potential for drug-drug interactions was found. This was for Resident #131. On 10/27/10, the consultant pharmacist provided a report that included, ""____ takes warfarin (Coumadin) and is also on other medications which may have pharmacodynamic and / or pharmacokinetic interactions: furosemide, acetaminophen, Lexapro, metoprolol, Nexium, and Ropinirole."" The recommendation included, ""When changing doses, stopping or starting other medications in a resident on warfarin, please consider more frequent INR monitoring, until stable."" On 11/02/10 at 12:20 p.m., the ADR policy was discussed with the director of nursing (DON). She stated the pharmacy had not been sending the notices referenced in the policy. A short while later, the DON reported they had received a list of drugs that interacted with warfarin. On 11/02/10 at approximately 4:20 p.m., Employee #192 provided a copy of the document the DON had referenced. The document listed antibiotics and anti-infectives that interacted with warfarin. Among the drugs listed under the heading ""HIGH SEVERITY : Serious risk - Action must be taken"" were Bactrim, Ciprofloxacin, and Fluconazole. Next to this list of medications was ""Notify physician for warfarin dose reduction (as necessary) and repeat PT/INR per physician recommendation."" --- Part II -- Based on review of medical records, staff interviews, review of sign-out sheets for the emergency drug box in Building 2, and a counting of the number of doses of Bactrim DS in the emergency drug box, it was determined an accurate accounting of the dispensing of medications from the emergency supply had not been ensured. Resident identifier: Unknown, but possibly Resident #29. Facility census: 150. Findings include: a) Resident #29 an order for [REDACTED]. Review of Resident #29's medical record found the antibiotic had been scheduled to be started at 9:00 a.m. on 10/11/10. However, the box for the nurse's initials on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview at 9:57 a.m. on 10/27/10, Employee #53 said she had gotten the antibiotic from the emergency box. Then she paused and said she had given Tylenol, not the antibiotic. According to documentation on the MAR, Resident #29 did not receive the first dose of the antibiotic until 9:00 p.m. on 10/11/10. On 10/27/10 at 3:35 p.m., Employee #36 was asked to provide access to the emergency box. The sign out sheets were located in the medication room. According to the sheet for October 2010, no Bactrim DS had been administered from the emergency box. The information on the sheet indicated there should have been twenty (20) doses of Bactrim DS in the box. An actual count of the medication found there were nineteen (19) doses, not twenty (20) doses of Bactrim DS in the emergency box. It was unknown to whom the medication had been given. .",2014-03-01
11423,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,153,D,,,U2Q611,". Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, ""You Have the Right To:"" The first item under this title stated, ""1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing."" The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's records until after the hearing on 09/27/10, and she produced a release signed by the resident's legal representative on that date. .",2014-03-01
11424,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,309,G,,,U2Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was ""secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..."" Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after the initial assessment occurred shortly after the fall on the morning of 10/14/10, the physician was not notified of the fall or subsequent bruising to the resident's temple until the afternoon of 10/15/10, and no one at the facility recognized and/or was monitoring the resident for increased anticoagulant effects associated with administering Bactrim DS with [MEDICATION NAME]. Resident identifier: #29. Facility census: 150. Findings include: a) Resident #29 Record review revealed this [AGE] year old female was admitted to the facility in 2002. Her active [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) 6.5 mg and 7 mg alternating every other day, according to the physician's monthly recapitulation of orders for October 2010. Review of a lab report, dated 10/07/10, for [MEDICATION NAME] time (PT) and international normalized ratio (INR), both of which were used to evaluate blood clotting time, found the PT to be high at 28.5 (normal range is 11.9 - 25.4) and the INR to be within normal limits (WNL) at 2.7 (normal range is 2.0 - 3.0). The physician was notified and ordered the same dosage of [MEDICATION NAME] with a recheck of labs in four (4) weeks. Previously, on 09/07/10, Resident #29 ' s PT was elevated at 25.9 and her INR was WNL at 2.1, and no change in medication was ordered. Review of the nursing notes found an entry, dated 10/10/10 at 6:15 p.m., stating the physician was notified that the resident had an increased temperature of 101.9 degrees Fahrenheit (F). The physician ordered Tylenol 500 mg and a urinalysis (UA) and complete blood count (CBC) stat. The results were called to the physician on 10/10/10 at 11:00 p.m., and the physician ordered Bactrim DS was ordered twice daily for seven (7) days. Her temperature at this time was 98.7 degrees F. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/10 at 1530 (3:30 p.m.), the nurse's notes indicated the resident's legal representative was notified of the resident having a urinary tract infection, of her increased temperature on 10/10/10, and of the new order for Bactrim DS. The resident's temperature at this time was noted at 97.0 degrees F. On 10/13/10 at 1:00 a.m., the nursing notes indicated the resident's was not having any signs or symptoms of adverse reactions associated with the use of the antibiotic. She remained afebrile, denied pain / discomfort, and was resting in bed with eyes closed. The next nursing note, written by a licensed practical nurse (LPN - Employee #137) and dated 10/14/10 at 7:20 a.m., stated, ""Res(ident) found in floor @ bottom of bed. Res states she is OK, no visible injuries.... Res states she was going to the bathroom and fell , bed alarm was not on. Assessment completed, (symbol for 'no') c/o (complaint of) pain or discomfort. Will continue to monitor."" In this same note, the nurse recorded her vital signs as follows: blood pressure (B/P) - 138/78; pulse - 78; respirations - 18; temperature - 98.8 degrees F; O2 sat was 93% on room air. Oxygen was reapplied, and her O2 sat was 95%. The next nursing note, written by a registered nurse (RN - Employee #166) and dated 10/15/10 at 3:20 p.m., stated, ""Staff report pt (patient) had fall on 10/14/10. Noted bruising /c (with) hematoma to (L) (left) temporal area. Appeared to have difficulty opening (L) eye. Resident alert & speech clear. Pupils equal & reactive. B/P this am (morning) 136/64, O2 sat 90%, (pulse) 86, (respirations) 18. Dr. (name) notified & made aware of current status. Dr. (name) stated he was unaware of fall. New order received to send resident to (Hospital #1) ER for evaluation. Resident is currently on blood thinner. POA (power of attorney) was notified."" The next nursing note, dated 10/15/10, at 4:15 p.m. stated, ""TC from (Hospital #1) ER. Resident being sent to (Hospital #2); has a subarachnoid bleed."" -- 2. Review of Hospital #1's records found Resident #29 had critical lab values of PT greater than 100 (normal range is 20.5 - 30.0, with critical values greater than 39), INR of 11.9 (normal range is 2.5 - 3.5, with critical values greater than 4.0), and PTT (partial [MEDICAL CONDITION] time) of 83 (normal range is 27 - 32) on 10/15/10 at 1526 (3:26 p.m.). The resident's red blood cells were low at 3.61 (normal range is 4.5 - 6.3), hemoglobin was low at 11.6 (normal range is 12.1 - 15), hematocrit was low at 33.9 (normal range is 35.8 - 46). The results of a CT scan of Resident #29's brain without contrast, dated 10/15/10, noted: ""Findings: There is punctate hemorrhage of the left frontal lobe. There is no extra axial component. There is a large, left frontal scalp hematoma. Sulcal and ventricular prominence correlation with atrophy. There is no midline shift. There is no calvarial fracture."" Under the heading CT Brain Impression was: ""1. Acute left frontal lobe parenchymal hemorrhage. 2. Generalized cerebral atrophy. 3. Large, left, frontal scalp hematoma."" The resident received 8 units of fresh frozen plasma and 30 mg of Vitamin K and was transferred to Hospital #2's neurology intensive care unit for a neurosurgical consultation on 10/15/10; she was subsequently admitted there at 2352 (11:52 p.m.), according to Hospital #2's discharge summary. -- 3. The discharge summary from Hospital #2, dated 10/20/10, under the heading Admission History and Physical stated: ""This was a transfer from (Hospital #1). The patient initially is a resident at Heartland of Beckley. The patient apparently fell down. The patient was not taken to the hospital at that time. After a day (sic) refer to consultation with the family. The patient was sent to (Hospital #1). At Hospital #1, the patient was found to have (sic) subarachnoid hemorrhages. The patient was subsequently transferred to the Neuro ICU here at (Hospital #2) for neurological evaluation. On presentation to (Hospital #1), patient ' s blood pressure was 170/74. The patient's INR was noted to be 11.9. The patient did receive a course of Bactrim previously while at Heartland of Beckley."" Under the heading Hospital Course was stated, ""... I believe patient's subarachnoid hemorrhage is secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..."" -- 4. Review of the resident's resident assessment protocol (RAP) for falls with an effective date and time of 06/29/10 at 11:09 a.m. stated, "" ... resident was walking back from bathroom and slid and fell (sic) improper footware (sic) pt educated on use of proper footware (sic) improper footware (sic) removed (sic) assessed for injury (sic) none noted (sic) neuro checks started (sic) md and poa aware."" An off-cycle falls RAP, with an effective date of 10/14/10 at 08:34 a.m., was completed by one (1) of the assistant directors of nursing (ADON - Employee #192) and signed on 10/16/10. It stated, ""Fall care plan reviewed and remains in place. No new recommendations made during IDT (interdisciplinary team) review."" - The Care Plan Focus for ""At risk for falls due to Cognitive (sic) impairment, pain, unsteady gait, walks without assistance, low oxygen saturations from not wearing oxygen, [MEDICAL CONDITION]"", which was initiated on 04/11/07, contained the goal of ""No injury requiring transfer to hospital."" The following interventions to achieve this goal were initiated on 04/11/07: ""Monitor for and report development of pain, bruises, change in mental status, ADL function, appetite or neurological status for at least 72 hours after a fall. Administer medications as ordered and monitor for effectiveness. Minimize environmental clutter. Have commonly used articles within easy reach. Encourage to transfer and change positions slowly. Reinforce need to call for assistance. Encourage and assist as needed to wear proper and non slip footwear. Encourage to use assistive devices: walker."" On 10/04/07, the IDT added: ""Give medication as ordered."" On 12/31/08, the IDT added: ""Educate staff to not leave resident unattended."" On 06/25/09, the IDT added: ""Educate resident on the use of call light and asking for assistance."" On 09/24/09, the IDT added: ""Sensor pad to bed at all times."" On 10/18/09, the IDT added, ""Anti-rollbacks to W/C (wheelchair)."" On 03/19/10, the IDT added: ""non (sic) skid shoes as tolerate (sic)."" (Note that several of the ""newer"" interventions were very similar to interventions that had been in place since 04/11/07.) - The Care Plan Focus for ""Anticoagulant therapy to treat [MEDICAL CONDITION]: At risk for adverse effects"", which was initiated on 04/11/07, contained the goal of ""Resident will have no adverse effects from anticoagulant use such as (sic) not limited to bruising, bleeding, blood in stool / emesis, etc."" Interventions to achieve this goal included: ""Monitor lab values and report results to physician. Monitor for and reports (sic) adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Provide education to family / resident about safety precautions. Administer medications per physician orders. Monitor for S/S (signs / symptoms) of [MEDICAL CONDITION] such as pain (sic) redness in ext (extremities)."" The last revision to this care plan was made on 10/27/09, beyond updating to the goal ' s target date. -- 5. The LPN who received the order from the physician on 10/10/10 at 11:00 p.m. (Employee #53) was interviewed at 9:57 a.m. on 10/27/10. Employee #53 said when she called the physician she did not tell him specifically what medications the resident was already receiving. She said the pharmacy usually calls before sending a medication if there would have been any problems with drug-to-drug interactions. - The nursing assistant (NA) who showered Resident #29 on day shift on 10/14/10 (Employee #31) was interviewed at 10:20 a.m. on 10/27/10. Employee #31 reported that, after lunch on 10/14/10, she noted a knot on the resident's head and bruising to the resident's hand, and the resident told her she fell . She said when she was on the way to the shower with the resident, she told the medication nurse (Employee #82, an LPN). He looked at the resident's head, administered a medication to the resident, and the resident was given a shower. Employee #31 said the resident was taken back to her room. She did note that the resident appeared to be having increased congestion. A review of Employee #31's statement taken by the director of care delivery (Employee #192) on 10/16/10 found the following: ""States she took over care of resident on 10/14 AM (morning) when other CNA (certified nursing assistant) was pulled to another unit. State she saw a large raised area with a bruise stating to form on resident's (L) temple area. States this was around noon, during resident ' s shower. States she brought it to the attention of the nurse '(Employee #82 ' s first name)'. States resident's behavior was normal & speech was normal."" Review of the Shower / Skin Observation Report for 10/14/10, completed by Employee #31 and signed by Employee #82, did not show any bruising or abnormalities for the resident. - The LPN who assessed Resident #29 after she was found on the floor at 7:20 a.m. on 10/14/10 (Employee #137) was interviewed at 10:25 a.m. on 10/27/10. She reported having been told of the fall by a NA (Employee #93) at the start of the shift. She said the resident was sitting in the floor upright with her legs out in front of her. The bed alarm was not on and was not sounding. She said she did a head-to-toe assessment of the resident and found no bruising or signs of injury. She indicated she checked the resident's head, back, and legs, as she was afraid the resident might have broken a hip. She also said she thought she started a neurological evaluation flow sheet but was told it could not be found. A review of Employee #137's statement taken by Employee #192 on 10/14/10 at 0830 (8:30 a.m.) found the following: ""Nurse stated that resident had a fall around 0730 and that she found no apparent injuries. Stated resident denied any pain or discomfort. States she notified Dr. (name) and MPOA (medical power of attorney) of the fall and completed an incident report. State she initiated neuro checks because the fall was not witnessed. No noted abnormalities at that time."" Elsewhere in witness statement for was written: ""Staff member became ill shortly after the incident and was taken to the hospital by EMS. Unable to locate neuro check sheet."" - The resident's October 2010 MAR indicated [REDACTED]. Review of the MAR for 10/14/10 found Employee #82 only gave the resident [MEDICATION NAME] 100 mg at 2:00 p.m. on that date, as he was reassigned to that area when Employee #137 was sent out to the emergency room . He stated, ""(Employee #31) said the resident had a bruise on her head. I looked at it. I went out and looked at the book for acute documentation. I did not know if it was documented. I don't recall saying anything to (Employee #134) who I reported off to (at 3:00 p.m.)."" A review of Employee #82's statement taken by Employee #192 on 10/16/10 found the following: ""Stated he took over med cart for nurse that left due to illness, along with (Employee#134), LPN. States he did note a bruise to the L temple area of the resident, but (sic) had been told it was already there from a fall. States he did not know when the fall occurred."" - An interview was conducted, on 10/27/10 at 11:30 p.m., with the LPN who received report from Employee #82 at 3:00 p.m. on 10/14/10 (Employee #134). Employee #134 said she worked from 7:30 to 4:00 p.m. on 10/14/10 as a treatment nurse. The October 2010 treatment record was reviewed with her at this time. She said she checked the resident's sensor pad and oxygen on 10/14/10, but she did not remember at what time. She thought it was before breakfast (before 8:30 a.m.). She reported that she helped Employee #82, after Employee #137 was sent out to the emergency room , with medications and doing treatments. She did not know anything about the resident's fall on 10/14/10. - A review of a statement taken from Resident #29 by Employee #192 on 10/15/10 revealed the following: ""Resident sitting up on side of bed. Bruising noted to (L) temple / forehead area. Resident alert and answering appropriately to my questions. When asked if she had any pain, she answered, 'my head'. When asked if she remembered fall she stated, 'I'm not sure'. When asked where her head hurt she stated 'Inside and out'. Resident sent to (Hospital #1) within 30 minutes of my conversation with her."" - A review of a statement taken from Employee #72 (a nursing assistant) by Employee #192 on 10/15/10 revealed the following: ""CNA states that she noted a bruise to the (L) temple area of the resident around 0830 (8:30 a.m.) on the morning of 10/15/10 when she took her breakfast tray to her. States that the nurse was aware of the bruise at that time."" - A review of a statement written on 10/18/10 by Employee #166 (a registered nurse assigned to Resident #29 on the morning of 10/15/10) revealed the following: ""I had a wing and part of another wing (we were short nurses). I received report from night shift (name). No mention of a fall or injury to the resident was made during report. I gave her morning meds first. I noticed bruising to the left side of her temple area. I took her VS (vital signs) and they were normal. I had to wake her to take her meds. She was 'groggy' but sat up and took her pills for me. I questioned some other staff and they stated she had a fall the morning before. I assumed her bruising was from the fall. When I reviewed the chart there was no documentation of any injury. I recognized the resident was on [MEDICATION NAME]. I went to assess her neurologically and found her to be WNL but C/O pain to (L) eye. I notified Dr. (name) of fall (sic) 10/14 & injury noted @ this time. Dr. (name) stated he was not notified and asked that resident be sent to ER."" -- 6. Review of the pharmacy manual's policy titled ""Adverse Drug Reaction"" from Omnicare, Inc (last revised 01/10/06), which was provided by the facility ' s administrator at approximately 9:00 a.m. on 10/27/10, found: ""ROCEDURE: The pharmacy will identify potential ADRs (adverse drug recations) by reviewing any drug therapy that appeared to cause: - Discontinuation of therapy - Patient hospitalization - Treatment with another drug used for allergic reactions - Significant patient illness - Threat to life or death. ""The pharmacist will document the potential adverse drug reaction on the Adverse Drug Reaction Log ... noting severity level. ""The pharmacy operating system is set to identify First Data Bank (FDB) levels 1, 2, and 3 drug interactions for the dispensing pharmacist at the time of order entry. ""The dispensing pharmacist evaluates the potential seriousness and immediacy of the drug interaction in the individual using their professional judgment and the information provided by FDB. Factors such as the person's age, comorbidities, and concurrent drug therapies area taken into consideration ..."" ""[MEDICATION NAME] Interactions: ""a) Determine if the drug interaction potential is serious and predict the timing of the interaction as advised by FBD. ""b) Recommend an alternate medication if possible ... or determine if a [MEDICATION NAME] dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention ...."" -- 7. Review of the facility's policy titled ""Neurological: Neurological Evaluation"" (dated 3/2010) found: ""PURPOSE: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluation may be compared and changes in neurological status may be determined. ""USE: - Following a witnessed fall (when a patient has hit his/her head) - Following an un-witnessed fall (when a head injury may be suspected) - Following a patient event which results in a known or suspected head injury (i.e.: hemorrhagic stroke) ... ""PROCEDURE: ""1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. ""2. Notify physician of specific patient event, initial findings, and baseline neurological evaluation. ""3. Obtain orders for subsequent neurological evaluations, diagnostic studies or other medical care. ""4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x 4, then every 1-hour x 4, then every 8-hours x 9 (for the next 72 hours). ""NOTE: More frequent neurological evaluations may be necessary if clinically indicated or as ordered per physician. ""5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations. ""6. Evaluate level of consciousness and document 'Y = Yes or N = No' responses to the following: - Alert - Lethargic - Semi-comatose - Comatose ""7. Evaluate level of orientation and document 'Y = Yes or N = No' responses to the following: - Oriented to person - Oriented to place - Oriented to situation ""8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil reaction for both the left and right eyes. Document using the following responses: - E = equal pupil size - U = unequal pupil size - R = reacts to light - NR = no reaction to light ""9. Evaluate motor movement by providing patient with simple motor commands. Document 'Y = Yes or N = No' responses to the following: - Moves right upper limb - Moves left upper limb - Moves right lower limb - Moves left lower limb - Facial symmetry ""10. Evaluate communication / language by providing simple communication commands. Document 'Y = Yes or N = No' responses to the following: - [MEDICAL CONDITION] - Receptive [MEDICAL CONDITION] - Speech slurred - Communication changes ""11. Evaluate for unusual / new observations. Document observation responses using the following: - W = Weakness - T = Tremors - D = Dizziness - H = Headache - V = Vision changes - N = Numbness - O = Other ""12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: - Blood pressure - Pulse - Pulse Ox % (Oxygen Saturation) - Temperature - Respiration rate - Respiration pattern -- N = Normal / Regular / Unlabored -- AB = Abnormal (i.e.: Labored, Kussmaul's , Cheyne-Stokes or Apnea) ""NOTE: Pay close attention to respiratory patterns. Notify physician regarding any 'Abnormal' findings or any changes in respiration rate or pattern. ""NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations. Document physician notification in Progress Notes. ""13. Notify the family / caregiver of patient condition an devaluation findings. ""14. Communicate event, interactions, and plan of actions using center specific systems (i.e. shift to shift reports, 24-Hour Reports, Eagle Room team meeting and alert charting)"" - Random confidential nursing staff interviews found that evidence of ongoing neurological evaluations of Resident #29 could not be found. Although Employee #137 (who first assessed her after she was found on the floor on the morning of 10/14/10) reported she completed an initial neurological exam, evidence of that initial assessment could not be found. This lack of on-going neurologic assessments was confirmed during an interview at exit with the facility administrator at 4:30 p.m. on 11/02/10. -- 8. The facility's ""Practice Models Charting Alert"" (dated 08/11/06) stated: ""Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status ""Guidelines: The alert charging process includes documentation of a patient's condition that warrants alert charging, the decisions and actions of staff related to the patient's condition and the patient's response to interventions implemented - Situation for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within. Some examples may include, but are not limited to: -- Change of condition, e.g. flu symptoms -- Accidents -- New admission or re-admissions -- Signs and symptoms of infection -- Skin alterations, e.g., skin tear, bruise, rash - The Alert Charting process includes, but is not limited: -- Documentation of patient evaluation findings, physician notifications and responses, family notification and any new orders or instructions received in the interdisciplinary progress notes or nursing notes -- Initiation of an Acute Care Plan including the patient ' s problem or need, goal, and interventions planned to manage the patient ' s condition -- Addition of patient name and information to the Alert Charting Log -- Update to the Change in Status Report, 24-hour Report -- Inclusion of information in shift-to shift report -- Notification of nurse supervisor, IDT members and other staff as needed -- Review of patient status during Eagle Room meetings - Documentation for alert charting occurs each shift for a minimum of 72 hours - Licensed nurses reference the Alert Charting Log at the start of each shift to identify patients requiring continued follow-up and alert documentation - Documentation related to the alert charting process may include, but is not limited to: -- Patient evaluation pertinent to the condition identified as the acute event -- Vital signs -- Presence or absence of pain -- Complaints and/ or behavior problems -- Changes in activities of daily living -- Patient response or outcomes - Remove patients form Alert Charting Log and discontinue Acute Care Plan when patient status has stabilized or the condition or symptom has resolved."" There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. Review of the ""Change In Status Worksheet / 24 Hour Report"" for 10/10/10 through 10/14/10 revealed no mention of Resident #29's condition and/or status except for on 10/10/10, when a nurse wrote: ""Give Tylenol 500 mg PO now D/T (due to) increased temp. U/A and CBC stat."" - The ""Change In Status Worksheet, 24-Hour Report Practice Model"" (dated 08/11/06) stated: ""Purpose: To provide an interdisciplinary communication tool that may be used to identify patient with a change in condition requiring intervention and follow-up. ""Guideline: ""- Complete form per directions and use narrative section for additional information as needed ""- Information includes but is not limited to: -- Admissions -- Unplanned discharges -- Change in condition, e.g. improvement or deterioration in physical, mental and psychological status -- Unstable condition -- Incidents / accidents -- New / discontinued medication orders -- Abnormal lab results -- Pain level > or = 4 -- Patient / family concerns -- Notification of physician, family / responsible party, administrator and/or ADNS -- Documentation completed: Nursing admission evaluation, off-cycle RAP, progress RAP, progress notes -- Nurse's initials ""- Interdisciplinary team members may enter any identified change of condition requiring clinical follow-up ""- Use report to communicate concerns at morning and after Eagle Room meetings ""- Use report during shift change to communicate patient information and needed follow up ""- Review report to confirm follow-up, notification and documentation of patient needs are complete"" - There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. -- 10. Review of the pharmacy manual's ""Policy #4.1 Prescriber Authorization and Communication of Orders"" (dated 12/01/07) found: ""PROCEDURE: "" ... 3. Verbal Orders: ""3.1 The facility's licensed nurses should contact the resident's physician where there is a change in condition that may require a new medication or a renewal of an existing order. ""3.1.1. Before contacting the physician / prescriber, the Facility's licensed nurses should assemble the necessary clinical information. This information may include, but is not limited to: vital signs, recent laboratory or diagnostic study results, recent medication orders, residents' response to medication, and possible adverse drug reactions."" No one at the facility recognized the possible adverse drug reaction associated with simultaneously administering Bactrim DS with [MEDICATION NAME]. .",2014-03-01
11425,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,520,E,,,U2Q612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's quality assessment and assurance committee failed to identify quality deficiencies of which it was (or should have been) aware and develop and implement plans of action to correct these quality deficiencies. This resulted in the facility's continuing non-compliance with the Medicare / Medicaid conditions of participation. During the current survey from 01/03/11 through 01/07/11, the facility failed to correct deficient practices cited during previous survey events that concluded on 09/01/01 and 11/02/10, with respect to the following regulatory requirements: Comprehensive Care Plans (F279), Quality of Care (F309), and Pharmaceutical Services (F425), resulting in repeat deficiencies in these areas. These deficient practices affected three (3) of ten (10) sampled residents and presented the potential for more than minimal harm to more than an isolated number of residents at the facility. Resident identifiers: #150, #151, and #152. Facility census: 142. Findings include: a) Quality of Care 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Quality of Care (F309) resulting in findings of deficiencies at a level of actual harm to an isolated number of residents during two (2) previous survey events at the facility, which concluded on 09/01/10 and 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. 2. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. 3. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. (See also citation at F309.) -- b) Pharmaceutical Services (F425) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Pharmaceutical Services (F425) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. 2. Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident did not receive her first dose of [MEDICATION NAME] at the facility until the evening of 12/12/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. 3. Resident #152 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident missed twelve (12) scheduled doses of [MEDICATION NAME] between 6:30 p.m. on 12/02/10 and 9:00 a.m. on 12/06/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. (See also citation at F425.) -- c) Comprehensive Care Plans (F279) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Comprehensive Care Plans (F279) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. 2. Resident #150, who was sent to the emergency room at a local hospital on the early morning of 11/27/10 for rectal bleeding with clots, did not have a current care plan (as of 01/06/11) to address the need to assess and monitor for [MEDICAL CONDITION]. 3. Resident #151, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. (See also citation at F279.)",2014-03-01
11426,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,309,G,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. These practices had the potential to result in more than minimal harm to an isolated number of residents. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her nursing notes revealed the following consecutive entries: - The admission nursing note, dated 11:00 p.m. on 12/10/10, stated,""... Resident appeared anxious and wanted to call her niece. The Resident (sic) phone was given to Resident and this appeared to have a calming affect (sic). ... VS (vital signs) are WNL (within normal limits) excluding pulse possibly D/T (due to) anxiety experienced when first arriving. ... Resident is A/O (alert / oriented) x's (sic) /c (with) confusion noted. ... All meds sent to pharmacy STAT and pharmacy was notified and stated they would be sent. ... There appear to be (symbol for 'no') s/s (signs / symptoms) of acute distress noted at this time. ..."" - A nursing note, dated 12/11/10 at 11:45 a.m., stated,""... Alert / oriented to person, place and time, But (sic) does not answer questions appropriately. (Arrow pointing up) confusion to situation / reasons for being admitted to HL (Heartland). ..."" - A nursing note, dated 12/11/10 at 11:41 p.m., stated, ""OT (occupational therapy) orders noted ..."" - A nursing note, dated 12/11/10 (time illegible), stated, ""Res (resident) OOF (out of facility) until approx 1130 - 12 noon. Ref (refused) shower upon arrival. 'I just got back from the Hospital.' ..."" - A nursing note, dated 12/13/10 at 11:45 a.m., stated, ""A/O x 3 (alert and oriented to person, place, and time). Confusion noted, Demanding (sic) argumentative (illegible) meds, explained med regimen several times /s (without) success D/T confusion."" - A nursing note, dated 12/13/10 at 4:30 p.m., stated, ""Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about [MEDICATION NAME] & [MEDICATION NAME]. pharmacy (sic) states that a script is needed for [MEDICATION NAME] & [MEDICATION NAME] had been sent. ..."" Review of the resident's physician orders [REDACTED]."" Review of Resident #151's hospital records revealed the physician who examined her wrote in the ER, under the heading ""Clinical Impression"", ""Anxiety / Panic Attack"". She was treated with intravenous [MEDICATION NAME] and returned to the facility at approximately 11:30 a.m. on 12/11/10. Review of the admitting orders found the resident was prescribed [MEDICATION NAME] 1 mg twice-a-day (bid) for anxiety and [MEDICATION NAME] (generic name for [MEDICATION NAME]) 50 mg at bedtime for depression / anxiety. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials documented at 10:00 p.m. with the following statement, ""Refused all pm (evening) meds (medications) because [MEDICATION NAME] & depression med was not available."" Review of the MAR found the resident also did not receive her 9:00 a.m. dose of [MEDICATION NAME] 1 mg on 12/12/10. After her return to the nursing facility on 12/11/10 (after having been treated with IV [MEDICATION NAME] for anxiety / panic attack), the facility failed to obtain and administer two (2) consecutive scheduled doses of [MEDICATION NAME] to treat her anxiety. She did not receive her first dose of [MEDICATION NAME] at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's [MEDICATION NAME] until 9:25 p.m. on 12/12/10. -- b) Resident #152 1. Review of Resident #152's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. According to recent assessment data, she was alert / disoriented to person, place, and season, had short and long-term memory impairment, and her cognitive skills for daily decision-making were moderately impaired. She was totally dependent on staff for the performance of all activities of daily living, had partial loss of voluntary movement with limitations in range of motion on both sides in her upper and lower extremities, and was incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. Further review found the resident was receiving [MEDICATION NAME] 5 mg (blood thinner) daily, which placed her at high risk for bleeding. - Review of Resident #152's nursing notes found the resident was readmitted to the facility on [DATE], following treatment in the hospital for UTI [MEDICAL CONDITION]; her [DIAGNOSES REDACTED]. She went back out to the hospital on [DATE] for the insertion of a gastrostomy tube and returned to the facility again on the evening of 12/20/10. According to a nursing note dated 12/26/10 at 12:30 a.m., ""Resident sent to (initials of local hospital) ER (emergency room ). Order received via telephone from Dr. (name of physician). See SBAR (Situation / Background / Assessment / Request form)."" The next consecutive note, dated 12/26/10 at 7:10 a.m., stated, ""Called (initials of local hospital) ER. Resident admitted to (initials of local hospital) D/T (due to)[MEDICAL CONDITION], mental status change, & respiratory compromise."" Review of the electronic form referred to as the ""SBAR"", dated 12/26/10 at 12:45 a.m., found under the heading ""Situation"": ""O2 sats (blood oxygen saturation levels) decreased to 72% with O2 @ 2.5L NC (oxygen at 2.5 liters / minute via nasal cannula). airways (sic) suctioned (sic) O2 (sic) increased to 80%. NEB (nebulizer) tx (treatment) administered. Lung sounds congested. O2 icreased (sic) to 3L via NC S (sic)."" Under the heading ""Background"", the author noted that medical information pertinent to this event included, ""Fall on 7p-7a (7:00 p.m. to 7:00 a.m.) shift on 12/24/2010, recent peg tube placement, increased temp of 101.0."" The author also noted the resident had exhibited a decrease in her level of consciousness, and increased heart rate of 148 beats per minute with an irregular rhythm, wheezes when checking her lung sounds, and the resident's skin color was pale. Under the heading ""Assessment (RN) / Appearance (LPN/LVN)"", the licensed practical nurse (LPN) completing the form noted, ""Resident (sic) skin warm, clammy. Pale in color. SOB (shortness of breath) noted."" Under the heading ""Request"", the author noted having contacted the resident's physician and obtaining an order to ""Send resident to (initials of local hospital) ER. "" Review of the resident's physician progress notes [REDACTED]. (""Rhonchi"" or ""wheezes"" are abnormal breath sounds caused by air moving through airways narrowed by [MEDICATION NAME], swelling, or partial airway obstruction.) Review of nursing notes from her previous stay, from 12/02/10 to 12/13/10, revealed the resident was congested and required suctioning and aerosolized breathing treatments, with deep suctioning and a chest x-ray ordered on [DATE]. Review of her current care plan, with a print date of 09/01/10, revealed the following problem statement: ""Potential for respiratory impairment related to [MEDICAL CONDITION]."" The goal associated with this problem statement was: ""Resident will have no acute episodes of respiratory distress such as, but not limited to SOB, dyspnea, cyanosis, aspiration (sic)."" Interventions to assist the resident in achieving this goal included: ""... Monitor lung sounds and VS (vital signs) as needed. Report abnormalities to physician. ... Monitor for and report adverse changes in respiratory rate, cough, respiratory effort, sputum color / consistency. ... "" Review of nursing notes from the date of her readmission to the nursing facility on 12/21/10 until her transfer to the hospital on [DATE] found no evidence to reflect the licensed nursing staff was routinely assessing / monitoring the resident's respiratory system for abnormal breath sounds after the physician identified the presence expiratory rhonchi, although the licensed staff periodically noted the resident's respiratory rate and blood oxygen saturation levels. - Further review of the resident's current care plan found the following problem statement: ""Urinary incontinence related to effects of [MEDICAL CONDITION]."" The goal associated with this problem statement was: ""Will have no complications due to incontinence such as, but not limited to UTI, skin breakdown (sic)."" Interventions to assist the resident in achieving this goal included: ""...Monitor for and report any changes in amount, frequency, color or odor of urine or continency (sic). ... Monitor for and report any S&S (signs and symptoms) of UTI such as flank pain, c/o (complaints of) burning / pain, fever, change in mental status, etc ..."" The medical record contained no nursing notes or other evidence that licensed nursing staff was assessing / monitoring the resident for signs and symptoms of UTI. - The resident was admitted to the hospital on [DATE] with a temperature of 101.0 degrees Fahrenheit (F); the resident's hospital [DIAGNOSES REDACTED]. - 2. Review of Resident #152's medical record found a nursing note, dated 12/05/10 at 2:30 p.m., documenting that Resident #152 sustained a witnessed fall. A nursing note, dated 12/07/10 at 10:00 p.m., documented the following, ""... Resident did have a fall on 12/5/10 at 2:30 p.m. Neuro Checks started at 10 pm to rule out neurological damages..."" Because of her daily use of [MEDICATION NAME], Resident #152 would have been at high risk for intracranial bleeding if she had struck her head as a result of this fall. Review of the neurological evaluation flow sheet found that nursing staff did not begin monitoring the resident for potential neurological compromise until 10:00 p.m. on 12/07/10, approximately fifty-five (55) hours after the resident's fall. In an interview was conducted on 01/07/11 at 3:45 p.m., the director of nursing (DON - Employee #15) was asked when nursing staff should have started neuro checks after the resident's fall. The DON stated that neuro checks should not have waited and staff should have started them immediately. - 3. Medical record review also revealed Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with a [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to the facility's failure to obtain pharmaceutical services in a timely manner. .",2014-03-01
11427,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,425,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admitting orders found the resident was prescribed Xanax 1 mg twice daily for anxiety and Doxepin 50 mg at bedtime for depression / anxiety. Review of her nursing notes revealed a note, dated 12/13/10 at 4:30 p.m., stating, ""Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about Xanax & Sinequan. pharmacy (sic) states that a script is needed for Xanax & Sinequan had been sent. ..."" Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the back of the MAR found a nurse's initials documented at 10:00 p.m. with the following statement, ""Refused all pm (evening) meds (medications) because Xanax & depression med was not available."" Further review of the MAR indicated [REDACTED]. She did not receive her first dose of Ativan at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's Xanax until 9:25 p.m. on 12/12/10. -- b) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no Xanax from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving Xanax. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered Xanax due to the facility's failure to provide pharmaceutical services in a timely manner. .",2014-03-01
11428,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-11-11,241,D,,,6V1A11,". Based on observation, resident interview, and staff interview, the facility failed to promote care for one (1) of four (4) residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Observation and interview revealed one (1) resident did not receive prompt assistance with incontinence care during a meal time. Resident identifier: #77. Facility census: 141. Findings include: a) Resident #77 Observation, on 11/11/10 at approximately 8:35 a.m., found Resident #77 turned on his call light. When interviewed, he reported he needed to be cleaned up. The resident said, ""I am in a mess."" At approximately 8:40 a.m., the resident's call light went off. At approximately 8:45 a.m., Employee #130 (a nurse aide) said she told the resident she would clean him up after she finished picking up the breakfast trays. On 11/11/10 at approximately 10:45 a.m., the interim director of nursing indicated he had spoken with this nurse aide, and Employee #130 did realize she should have provided Resident #77 with the assistance he needed before she finished picking up the breakfast trays. He agreed the resident's needs should have come before picking up trays after the breakfast meal. .",2014-03-01
11429,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,314,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a ""blackened area"" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as ""10"", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: ""Potential risk for skin breakdown d/t (due to) decreased physical mobility."" The goal associated with this problem statement was: ""Maintain intact skin integrity thru 09/21/10."" Approaches to be implemented to meet this goal included: ""up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode."" -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written, ""CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times."" Under the heading ""Analysis of the Incident: (apparent cause)"" was written, ""Poor bed mobility."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times."" -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following ""Uses"" for [MEDICATION NAME]: - ""Management of decubitus ulcers."" - ""Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. "" - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: "" The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. "" -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, ""We do weekly body audits."" When further questioned about how an area would not be recognized until it had become black, the nurse stated, ""It should have been caught before it was black."" .",2014-03-01
11430,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,157,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed, for one (1) of eleven (11) sampled residents, to notify the resident's legal representative or attending physician of a significant change in the resident's health status. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs and failed to collect / record, monitor, and report to the physician or the resident's legal representative any physical assessment data related to this resident's change in condition. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 5. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's legal representative. -- 6. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 7. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. .",2014-03-01
11431,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,309,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: ""Resident is at risk for constipation: limited mobility; medications; history of constipation."" The goal associated with this problem statement was: ""Resident will have bowel movments (sic) at least every three day s (sic) thru next review."" Interventions to achieve this goal included: ""Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order."" - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. .",2014-03-01
11432,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,327,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. (See citation at F309.) -- 5. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer them except when the resident refused. (See also citation at F309.) -- 6. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 7. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. .",2014-03-01
11433,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,225,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of incident / accident reports, review of self-reported allegations of abuse / neglect and injuries of unknown source, and staff interview, the facility failed to immediately report and thoroughly investigate injuries of unknown source and/or an allegation of neglect involving one (1) of eleven (11) sampled residents (#23) who was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. Record review, on 11/10/10, found a nursing note dated 10/25/10 at 11:30 a.m., stating staff identified the presence of swelling and bruising to Resident #23's left ankle and coccyx; these injuries were of unknown source. There was no evidence the facility immediately reported these injuries of unknown source to State officials as required or conducted a thorough investigation to identify possible cause(s) of the injuries and/or to ascertain whether they were the result of abuse or neglect. On 11/11/10, the facility's director of nursing (DON) produced an incident investigation report involving Resident #23, dated 10/26/10, stating staff discovered swelling and bruising to the resident's left ankle and bruising to the resident's coccyx at 11:00 a.m. on 10/26/10. Information recorded on this report suggested the bruising to the resident's ""posterior"" was the approximate size of the resident's wheelchair arm rest, and bruising may have been the result of contact between the resident and the arm rest while the resident was being transferred by mechanical lift. There was no evidence the facility immediately reported this to State officials as an allegation of neglect or made reasonable efforts to identify to which staff members may have been responsible. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 1. Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. - Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. - Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" - On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. When asked whether these injuries of unknown source were immediately reported and/or thoroughly investigated, the DON stated she did not feel the injuries were the result of abuse or that they required further investigation (even though the injuries could not have been self-inflicted, given the resident's physical limitations). This interview revealed that neither an incident report or an investigation of the injuries (which were identified on 10/25/10) could be located. There was no evidence the facility thoroughly investigated when the injuries of unknown source occurred. Additionally, there was no evidence of attempts to determine which facility staff members were present when the injuries occurred. -- 2. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report dated 10/26/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written: ""CNA (certified nursing assistant) (first name of Employee #50) was performing ADL's on resident /c assistance of (first name of Employee #60). They noted swelling & bruising to (L) (left) ankle & bruising to tailbone."" Documentation on the report identified the ""Date of Incident"" and ""Time Incident Occurred"" as 10/26/10 at 11:00 a.m., although the nursing note first recording the discovery of these injuries was written at 11:30 a.m. on 10/25/10. Under the heading ""Witness"" were written the names of two (2) nursing assistants (Employees #50 and #60). (As noted in the description of the incident, these staff members were not reporting the incident as having occurred in their presence; rather, they were the ones who discovered the injuries.) Under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" - The information on this report implied that the resident's injuries found on the morning of 10/25/10 may have been the result of inappropriate and/or unsafe technique by staff while transferring the resident via mechanical lift, which would constitute an allegation of neglect. However, no statements were obtained from the individuals identified listed as witnesses to the incident, nor were statements obtained from any direct care staff that had been assigned to care for the resident during any of the shifts preceding the date and time the injuries were noted. -- 3. Review of the facility's self-reported allegations of abuse / neglect and injuries of unknown source found no evidence of any self-report to State officials involving Resident #23 for either the injuries of unknown source referenced in the resident's nursing notes at 11:30 a.m. on 10/25/10 or the injuries said to have occurred at 11:00 a.m. on 10/26/10, which were attributed to inappropriate / unsafe technique used by staff when transferring the resident via mechanical lift. .",2014-03-01
11434,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,282,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, policy review, and staff interview, the facility failed to ensure licensed nursing staff followed physician's orders for two (2) of eleven (11) sampled residents. For Resident #23 who wore a splinting device on her right lower extremity, the licensed nursing staff failed to collect and record physical assessment data at a frequency of every four (4) hours as orderesd by the physician. For Resident #45, there was a lack of evidence to reflect that three (3) laxatives and two (2) nutritional supplements were administered in accordance with physician's orders. Resident identifiers: #23 and #45. Facility census: 84. Findings include: a) Resident #23 Review of nursing notes, dated 11/03/10 at 1:00 p.m., revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) [MEDICAL CONDITION] ([MEDICAL CONDITION] of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced [MEDICAL CONDITION] fibula accompanies the distal tibia fracture. Osteopenia is apparent."" - Review of physician's orders found telephone order, dated 11/04/10 at 11:00 a.m., for: ""(1) Resident (sic) wear splint to RLE (right lower extremity) @ (at) all x's (times). (2) Resident to be monitor (sic) QS (every shift) to ensure Brace in place properly. (3) RLE to be monitored Q4(symbol for 'hour') (every four (4) hours) and documented for CRT (capillary refill time), Temp (temperature) of skin, Color of skin below splint, Pulse below splint, Presence (sic) of [MEDICAL CONDITION] Above / Below splint. (4) [MEDICATION NAME] 5/500 i (1) PO (by mouth) at 8 AM D/T (due to) pain."" - Review of the facility's policy and procedure titled ""Cast Care and Observation - Medicare Documentation Guidelines"" staff was to monitor capillary refill time, skin temperature, color of digits, ability to move digits, presence of [MEDICAL CONDITION], and for facial grimacing or other signs and symptoms of pain. According to the policy, staff was to monitor and document the findings every four (4) hours. - The first evidence of monitoring of the resident's right lower extremity, in accordance with the above noted physician's order, was found in a nursing note at 2:30 p.m. on 11/04/10. The next entry in the nursing notes containing evidence of monitoring was recorded five and one-half hours later, at 8:00 p.m. on 11/04/10. Subsequent entries containing physical assessment data of the resident's right lower extremity were recorded in the nursing notes on the following dates and times: - on 11/05/10 at 12:30 a.m. - on 11/05/10 at 2:30 p.m. - on 11/05/10 at 8:15 p.m. - on 11/06/10 at 9:00 a.m. - on 11/06/10 at 1:00 p.m. - on 11/06/10 at 5:00 p.m. - on 11/06/10 at 8:00 p.m. - on 11/07/10 at 2:20 p.m. - on 11/07/10 at 6:50 p.m. - on 11/08/10 at 12:00 a.m. (late entry) - on 11/08/10 at 4:00 a.m. (late entry) - on 11/08/10 at 11:30 a.m. - on 11/08/10 at 8:00 p.m. - on 11/09/10 at 12:00 a.m. - on 11/09/10 at 1:30 p.m. - on 11/09/10 at 4:10 p.m. - on 11/10/10 at 3:00 a.m. Review of these entries found multiple gaps between assessments of greater than four (4) hours, with one (1) gap exceeding eighteen (18) hours between consecutive entries containing physical assessment data related to the resident's right lower extremity at 8:00 p.m. on 11/06/10 and 2:20 p.m. on 11/07/10. - During the exit conference, an interview with a registered nurse (Employee #20) revealed she had written these orders to assess Resident #23's leg and document every four (4) hours ""per our policies and procedures, and they (nurses) should have been doing it."" -- b) Resident #45 Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. - Review of the resident's September 2010 MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on 09/13/10, 09/14/10, 09/15/10, 09/18/10, 09/19/10, 09/20/10, 09/24/10, 09/25/10, 09/26/10, 09/27/10, 09/28/10, 09/29/10, and 09/30/10. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on 09/17/10 and 09/21/10. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's September 2010 MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on 09/24/10. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on 09/05/10, 09/15/10, 09/16/10, 09/17/10, 09/18/10, 09/19/10, 09/20/10, 09/21/10, 09/23/10, 09/26/10, 09/27/10, and 09/28/10 (with the last dose initialed as having been administered on 09/29/10). This represents a total of thirteen (13) doses not administered as ordered. - According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citations at F309, F325, and F514.) .",2014-03-01
11435,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,323,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's incident / accident reports, review of the facility's self-reported allegations of abuse / neglect, and staff interviews, the facility failed to provide adequate supervision and/or assistance devices to prevent avoidable accidents. One (1) of eleven (11) sampled residents (#23) was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. On 10/26/10, she was identified as having swelling and bruising to the left ankle and coccyx; these injuries were of unknown source, although the facility's investigative report revealed the bruising on the resident's coccyx may have been associated with contact with the resident's wheelchair armrest during a transfer within a mechanical lift. On 11/03/10, the resident was identified with swelling and redness to the right leg; she was subsequently diagnosed with [REDACTED]. There was no evidence the facility implemented any measures to protect this totally dependent resident from further injury after the first injury was identified. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. -- Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. -- Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" -- On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. This interview revealed that neither an incident report or an investigation of the injury of known source identified on 10/25/10 could be located. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report of an incident said to have occurred at 11:00 a.m. on 10/26/10. In the report under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). ""Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" -- On 11/11/10 at 12:25 p.m., the DON was asked to provide evidence of the content of the staff training provided and to whom this education was provided. The DON stated this information was not available, because she ""educated the staff that were on the spot that day."" This process did not assure all staff members who might utilize the mechanical lift with this resident, on all shifts, were educated. -- Review of the facility's abuse / neglect self-reports for the previous three (3) months revealed Resident #23 had sustained another of injury of unknown source on 11/03/10. Review of nursing notes, dated 11/03/10 at 1:00 p.m. (eight (8) days after the injury of unknown source to the left leg), revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) DVT (deep vein thrombosis) of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced fracture of the proximal fibula accompanies the distal tibia fracture. Osteopenia is apparent."" -- Review of facility records and staff interview revealed no evidence to reflect effective measures were implemented to prevent further injury to this totally dependent resident, after the resident was found to have bruising and swelling to her left ankle and coccyx. Eight (8) days, later she sustained fractures to her right leg. .",2014-03-01
11436,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,514,E,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the clinical record of one (1) of eleven (11) sampled residents was maintained in accordance with accepted professional standards and practices that are complete and accurately documented. Review of the closed record of Resident #45, who was transferred to the hospital on [DATE], found incomplete and/or inaccurate documentation including but not limited to: no entries in the nursing notes describing significant changes in her health status that started on [DATE]; no entries at all after [DATE] (to include no entry related to her transfer); multiple blanks where licensed nurses were to have initialed as having administered ordered medications; multiple instances where the nurses' initials were circled (indicating medication doses were not administered) with no corresponding documentation to explain why; and documentation on the resident's [DATE] activities of daily living (ADL) flowsheet for ADL performance said to have occurred on shifts after the resident had left the faciity on [DATE]. These reflected at pattern of deficient practices affecting a single resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. No documentation related to the resident's change in condition During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. - Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. - Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.9 Completeness ""Document all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment (including the reason for it). Make sure entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification."" ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" ""5.2.18 Notification or Communications If notification to the resident's physician or family is required, or a discussion with the resident's family occurs regarding the care of the resident, all such communication (including attempts at notification) should be charted. Include the time and method of all communications or attempts. The entry should include any orders received or responses, the implementation of such orders, if any, and the resident's response. Messages left on answering machines should be limited to a request to return call and does not meet the definition of notification."" -- 2. No documentation on the date of discharge Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to an assessment of the resident prior to her being sent to the hospital. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.17 Admission / Discharge Notes ""The resident's initial admission note and discharge summary should fully and accurately describe the resident's condition at the time of admission and discharge, respectively. Documentation should include the method / mode of arrival / discharge, resident's response to admission / discharge and physical assessment. When discharging a resident, take special care in documenting resident education when applicable including instructions for self-care, and that the resident / responsible party demonstrated an understanding of the self-care regimen."" -- 3. ADL Flowsheet According to documentation on Resident #45's [DATE] ADL flow sheet, the nursing assistants on all three (3) shifts on [DATE] provided assistance to the resident with dressing, eating / drinking, toilet use, hygiene, and bath / shower on [DATE]. Additionally, the resident was noted to have had at least one (1) bowel movement on each shift. Resident #45 transferred to the hospital before the end of day shift on [DATE] and was not physically in the facility for either the evening or night shift on [DATE]. -- 4. Medication administration records (MARs) Review of the resident's September MAR found an order for [REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no documented evidence to reflect that both doses of Senna Plus were administered daily in [DATE]. - According to the [DATE] MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. - According to Section 6.0 of the AHIMA LTC documentation guidelines: ""Medication and Treatment Records: ""Medication and treatment records (MARs and TARs) are derived from the physician orders [REDACTED]. ""Nurses place their initials in the blocks of the MARs and TARs form when medication or treatment has been administered. Based on physician orders, there should be no gaps noted in this documentation. ... ""Any medications or treatments given on a PRN (as needed) basis must be initialed, and information pertaining to the need for the PRN, documented either on the back of the MAR/TAR or elsewhere in the chart as defined by facility policy. Separate nurses note may also be required. ... ""Nurses will circle or otherwise indicate which medications or treatments were NOT administered. This would then require a documented explanation as to why the order could not be carried out. ...""",2014-03-01
11437,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,224,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide goods and services necessary to avoid physical harm and to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician and the resident's legal representative any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician that this resident, beginning on [DATE], was having excessively frequent BMs. (See also citation at F309.) -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""... Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" (See also citation at F309.) -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. (See also citation at F327.) -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. .",2014-03-01
11438,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,325,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure one (1) of eleven (11) residents, who was identified as being at risk for weight loss, received nutritional supplements in accordance with physician orders. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. According to her October 2010 recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""... Med pass (sic) 120cc (sic) bid. Glucerna 1 can po bid for supplement."" According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citation at F514.) .",2014-03-01
11439,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2010-11-17,159,D,,,TT3W11,". Based on a review of personal funds of residents deposited with the facility, facility policies for Resident Trust Fund / Valuables (revised 08/03/09), and staff interviews, the facility failed to obtain written authorization to manage personal funds for two (2) of eight (8) sampled residents (#91 and #90) who had personal funds deposited with the facility. Facility census: 89. Findings include: a) Resident #91 Review of facility records, with the business office manager (BOM - Employee #29), on the mid-morning of 11/17/10, found a Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #91 dated 04/07/10; this authorization form found was signed by a person who was designated by the resident to serve as medical power of attorney representative (MPOA) only. The resident's financial file did not include any information regarding the authority of this person to make financial decisions for the resident. The BOM reported the resident was unable to sign for herself and acknowledged the resident's MPOA did not have the authority to sign the document. -- b) Resident #90 Review of facility records, with the Employee #29, on the mid-morning of 11/17/10, found a Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #90 dated 02/10/10; this authorization form found was signed by a person who was designated by the resident to serve as MPOA only. The resident's financial file did not include any information regarding the authority of this person to make financial decisions for the resident. The BOM reported the resident was unable to sign for herself and acknowledged the resident's MPOA did not have the authority to sign the document. -- c) Review of the Resident Trust Fund / Valuables facility policy (revised 08/03/09), under ""Authorization to Manage Funds"", found: ""Every resident has the right to manage his/her funds. If the resident chooses to have the facility set up a trust fund in his/her name, the resident, agent, or legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form. By signing the form, the resident authorizes the facility to hold the resident's fund in a qualified Resident Trust Account....""",2014-03-01
11440,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2010-11-18,323,G,,,65CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision and/or assistive devices for one (1) of five (5) residents reviewed to prevent avoidable accidents. Resident #89, who had experienced a decline in physical condition and was diagnosed with [REDACTED]. There was no evidence the facility evaluated the resident's ability to be unsupervised in the wheelchair due to her condition at 9:00 a.m., her weakened condition due to pneumonia, and her potential weakness as the result of refusing both meals prior to the fall. The resident was not assessed to determine whether supervision to avoid an accident was necessary. The facility had not evaluated the risk of this resident having an avoidable accident or implemented any interventions to reduce the risk of a fall. Later that day, the resident was gotten out of bed and placed in a wheelchair so an air mattress could be placed on the bed. She was unsupervised in the wheelchair and was found on the floor at 4:23 p.m. on 10/13/10. She sustained injuries and required hospitalization . There was no evidence that staff, who placed her in the wheelchair, had been made aware the resident was put to bed earlier in the day because she was leaning forward in her wheelchair. Subsequently, the resident experienced a fall from the wheelchair with injuries. Resident identifier: #89. Facility census: 88. Findings include: a) Resident #89 When reviewed on 11/17/10 and 11/18/10, the medical record of Resident #89 disclosed this [AGE] year old female had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - On 10/13/10 at 9:00 a.m., a nursing note stated, ""Resident up in w/c (wheelchair) with 1 person assist leaning (sic) forward in w/c assisted resident back to bed."" A nursing note, dated 10/13/10 at 9:31 a.m., stated, ""Resident's daughter was upset over finding her mother slumped in her bed ...Resident has shown a steady decline over last several months. Oral intake is poor. Resident refuses to be fed."" A nursing note entry dated 10/13/2010 at 15:57 (3:57 p.m.) described that the resident was propelling herself in the wheelchair, and was found in the floor. Further review of the medical record revealed no interventions relative to safety and/or to prevent further falls. An additional nursing note, on 10/13/10 at 16:23 (4:23 p.m.), stated, ""Notified by staff that resident was found in the floor. Resident had been gotten out of bed to place air mattress on bed. Resident had been wheeling self about facility and then was found in the floor on A hall. Resident was found face down with a laceration to the R (right) eyebrow and cheek. Complained of pain to R hip."" The resident was transported to an area hospital. The medical record described the residents weakened Physical condition and continued decline. Documentation in the resident's medical record described a slow decline in her physical condition from the time of admission. The resident had acquired Clostridium difficile (C. diff - a condition that results in frequent diarrhea) after admission to the facility on [DATE] and, following treatment, had a negative stool culture on 10/05/10. The resident was diagnosed with [REDACTED]. The resident's oral intake was minimal from the time of admission. The resident's weight record stated an admission weight of 139.5# on 07/28/10 and a weight of 131# on 10/06/10. On 08/06/10, the resident was placed on the medication Megace to increase her appetite, and it was discontinued on 10/01/10. Meal intake reviews showed that, shortly before her hospitalization on [DATE], the resident's meal intake ranged from 0% (refusal) to 50%. The resident refused both meals prior to her fall and hospitalization on [DATE]. - A facility's occupational therapist (OT - Employee #3), who had worked with Resident #89 until shortly before her fall with injury, was interviewed at 10:30 a.m. on 10/18/10. When asked about her experiences with the resident and the resident's condition, the OT stated the resident had had a slow decline in her condition almost from the time of admission and, in the last few days prior to discontinuation of services, the resident had been less responsive and unable to follow direction. A nursing note, dated 10/06/10, stated, ""Resident to be discharged from therapy services today."" - The facility's director of nurses (DON), when interviewed on 11/18/10 concerning the resident's fall, stated she was fully aware of the resident's decline in several areas, to include her bout of [DIAGNOSES REDACTED], poor appetite and meal refusals, weight loss, and pneumonia, but that the resident had remained able to sit upright in her wheelchair. The DON did not know if facility staff who placed her in the wheelchair were aware the resident had been unable to sit up earlier in the day. The DON further confirmed the resident had not been re-evaluated for her ability to be independent in her wheelchair as her condition declined.",2014-03-01
11441,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2011-01-25,309,G,,,65CW12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records (both electronic and paper), staff interviews, review of in-service records, review of disciplinary action documents, review of controlled substances records, review of the facility's documentation regarding falls, review of the facility's investigations of falls and reportable events, and observations, the facility had failed to ensure a resident received appropriate and timely interventions for management of the onset of pain. The lack of pain management constituted actual harm to the resident. Review of documentation found a resident had sustained falls in December 2010. The last fall was noted to have occurred on 12/25/10. She later began to demonstrate both verbal and non-verbal indicators of pain. During this time, she also began to exhibit a limp and a decreased effort to ambulate. The onset of pain symptoms was evident beginning on the late morning of 12/31/10. A total of six (6) doses of Tylenol 650 mg were documented as given. The effectiveness of those doses was not documented (or documented in the negative), and documentation indicated the resident's pain symptoms persisted. The physician saw the resident in the afternoon on 12/31/10. He noted the resident was crying but did not order any additional pain medication. There was no evidence further treatment of [REDACTED]. On 01/02/11 at 23:39 (11:39 p.m.), the resident was sent to the hospital where it was found she had a [MEDICAL CONDITION]. Through review of medical records, review of the controlled substances sign-out book for Mary's Garden, staff interviews, observations, and review of documentation of in-services and disciplinary actions, it was determined the facility had identified and addressed the deficits in the provision of care related to pain management for Resident #50. This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/25/09) and before the start of this on-site revisit to a complaint investigation on 01/24/11. Resident identifier: #50. Facility census: 84. Findings include: a) Resident #50 During review of occurrences reported to the State in accordance with the ?483.13(c)(1)(ii), it was noted a report had been completed for Resident #50 on 01/03/11. The report indicated the resident had an injury of unknown source. She had been sent to the emergency room for complaints of pain, where she was found to have a displaced [MEDICAL CONDITION] hip. Record review revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]., and dementia with behavioral disturbances. -- 1. Review of the nursing entries and assessments found she had fallen on 12/09/10. A nursing entry for 12/09/10 at 18:09 (6:09 p.m.), by Employee #111 (a licensed practical nurse (LPN)) noted the resident had fallen in the last 72-hours. She had experienced a witnessed fall at the nurses' station. At that time, the resident was not exhibiting signs and symptoms of pain according to the nurse. A late entry on 12/10/10 at 2:09 (the author did not indicate the date or time of the original event for which this late entry was made), made by an LPN, noted the resident was ambulatory for short distances that morning. She was also noted to be unsteady of gait at times. On 12/12/10 at 13:14 (1:14 p.m.), Employee #29 (an LPN) noted the resident had fallen. The resident had been ambulating in the common area of the unit. The nurse wrote (excerpts typed as written), ""... (Resident's name) is experiencing pain. right hip sore-per resident. ..."" On 12/12/10 at 21:14 (9:14 p.m.), Employee #29 wrote the resident was resting in bed at that time. The note included (excerpts typed as written), ""Cont(inue) to monitor for bruising/ c/o's (complaints of) pain."" On 12/13/10 at 10:29 (8:29 p.m.), Employee #29 noted the resident was sitting in the common area with other residents. It was also noted, ""Ambulating slow-gait steady at this time."" The next nursing entry was at 19:57 (7:57 p.m.) on 12/19/10 by Employee #29. The resident was note to be ambulating in the common area. She refused to sit down or use a wheelchair. Her gait was noted to be unsteady. On 12/22/10 at 4:38 (4:38 a.m.), Employee #64 (an LPN) noted by that a body audit had been completed with no new areas found. On 12/27/10 at 16:12 (4:12 p.m.), Employee #29 noted the resident was ambulating with an unsteady gait. It was also noted staff had assisted the resident with ambulating several times that day. The nurse wrote (excerpts typed as written), ""Res(ident) will sit for a few min's (minutes) then gets up and ambulates."" On 12/29/10 at 10:17 (10:17 a.m.), Employee #49 (the director of nursing (DON)), spoke with the resident's son about the resident's lethargy and falls risk. The son stated he would rather not have a lap buddy or seat belt used at that time. Her medications were also discussed with the son - that [MEDICATION NAME] had been discontinued due to the possible side effect of muscle spasms. The psychologist had changed the resident's medication to [MEDICATION NAME], and she appeared to be a little more lethargic. Dosage reduction was to be discussed with a psychiatrist. The next entry was at 15:33 (3:33 p.m.) on 12/31/10 by Employee #113 (an LPN), who wrote (excerpts typed as written), ""Res c\o severe pain to R(ight) leg\knee. Visible signs of pain present: teary eyes, moaning\guarding area with movement. This nurse administered Tylenol per standing order. RN supervisor notified and assessed area. Dr. (name) present new orders received for X-ray to R knee and R femur. (X-ray supplier) notified and X-rays ordered STAT (immediately)."" On 12/31/10 at 16:33 (4:33 p.m.), it was noted the x-rays had been completed. On 12/31/10 at 22:24 (10:24 p.m.), Employee #64 (an LPN), wrote (excerpts typed as written), ""Res c\o severe pain to R leg\knee. Visible signs of pain present: teary eyes, moaning \ guarding area with movement. This nurse administered Tylenol per standing order. X-ray result from (x-ray supplier) are unremarkable. Dr. (name) notified."" On 01/01/11 at 04:54 (4:54 a.m.), Employee #113 (an LPN) wrote (excerpts typed as written), "" Resident continues to complain of severe R knee and leg pain. Tylenol given per standing order. Will continue to monitor."" On 01/01/11 at 09:33 (9:30 a.m.), Employee #113 noted (excerpts typed as written), ""Res cont to c\o pain to R knee \ leg. Tylenol per standing order administered at this time."" On 01/02/11 at 06:32 (6:32 a.m.), Employee #114 wrote (excerpts typed as written), ""Res had c/o pain upon waking this am. Tylenol gave at 6am. Will cont to monitor."" In the next entry, at 18:54 (6:54 p.m.) on 01/02/11, Employee #111 (an LPN) wrote (excerpts typed as written), ""Resident had continued throughout the day to exhibit s/sx (signs/symptoms) of pain ( facial grimace, moaning, tears) and grabs at right hip when staff attempt to help reposition her. Resident denies pain and states she doesn't know what to do, as explaination as to why she was crying. Spoke with Dr. (name) who ordered STAT xrays of her right pelvis and right hip. [MEDICATION NAME] 5/500mg one by mouth every four hours as needed. Dr. (name) to call in the medication to the pharmacy, have contacted (x-ray supplier) for STAT x-rays. Son, (son's name) notified of n/o's (new orders). ..."" The x-rays were noted to have been completed at 21:17 (9:17 p.m.) on 01/02/11. At 23:39 (11:39 p.m.) on 01/02/11, Employee #111 noted the x-ray had shown a ""right displace [MEDICAL CONDITION]."" She wrote the resident was transferred to the hospital for evaluation and treatment. -- 2. Review of the statements taken during the facility's investigation of the resident's fracture (written as faithfully to the original as possible, with the statements of some individuals having been broken into segments in order to place them in chronological order) found the following: 12/25/10 - Employee #99 (a nursing assistant - NA) - ""... Resident was lethargic mood, resident when gotten up in wheel chair, attempted getting up and walking. When she did attempt to walk had a limp on right side, didn't seem to be in pain. Resident wasn't on feet for any length of time because of possible falling on X-mas day. Resident seemed very lethargic for several days, wouldn't hardly eat or drink. Resident seemed to want to sleep a lot... I worked on 12/25/26/28/29/30/31/1 On these days (Resident's name) got out of bed most days between 9 A and 11 A then on Fri, 31st she slept later than usual when resident finally got out of bed she states she was hurting on right side & started crying."" 12/31/10, night shift - Employee #105 (NA) - ""(Resident's name) was lying in bed awake all night. My self and nurse kept going in there to check on her. When straightened up in bed, resident would turn back to her one side facing the door. The nurse asked her if she was in pain, resident stated that it was never ending. ..."" 12/31/10, days / evenings - Employee #113 (LPN) - This nurse noted the resident had slept later than usual. ""... the CNA's reported to me the pt was in pain when they brought her into the common's area. Upon assessment, pt had visible s/s of pain. She was holding her right knee, had tears in her eyes and was shaking. I administered Tylenol per physician's standing order. I then call Rehab unit for an RN to come over and assess pt. (Employee #60), RN assess pt. right leg and knee. She stated she would ask Dr. (name) to come over since he was in the building. Dr. (name) came over about 20-30 mins later and examined pt. He ordered a STAT x-ray of right knee and femur. ... completed x-ray around 4:30 p.m. ..."" 12/31/10, day shift - Employee #26 (NA) - ""On Friday 12-31-10 on 2:00 p rounds (Resident's name) was still in bed. Another aid & I got her up. She would not put any weight on her (R) side. She was tearful and complained of pain while holding her (R) knee. I asked her where she was hurting & she said everywhere. ..."" 01/01/11, night shift - Employee #20 (LPN) - This nurse noted the evening shift nurse had told her the resident had been complaining of pain and she had been given Tylenol. ""...was in the bed, she was restless during the night but did not attempt to get out of bed. Around 6am this nurse and CNA (Employee 37) went in to do last round on resident. After she woke up she had a grimace on her face. I asked resident if she was in pain and she said 'yes.' We asked her to show us where she was hurting and resident stated 'All over.' I lifted residents R Leg to put on a sock and resident grabed her R side. I went and got resident some Tynenol per standing order . . . I asked the oncoming nurse if she could try to get (Resident's name) something stronger for pain and I told her how she had grabed at her R side when I lifted her leg."" 01/01/11, day shift - Employee #26 (NA) - ""On Saturday 1-1-11 she complained of being in pain all day & refused to eat. . . ."" 01/01/11, days / evenings - Employee #113 (LPN) - ""... Tylenol administered at 9:30am with am meds. Pt was holding her right knee and had tears in her eyes. ..."" 01/01/11, evenings / nights - Employee #37 (NA) - ""... At around 4 pm I helped take her to the bathroom, it took two of us because She was telling us the She couldn't stand because She was hurting. I asked what was hurting her and She said 'I'm hurting all over' . She was like that for most of the rest of the shift, tearful and had a pained look on her face... She was up most of the night on the 11-7 shift. She never tried to get out of bed, but She was restless and saying she was hurting. At around six Sunday morning, (Employee #20), LPN & I went in to do our last round and She had finally went to sleep, upon checking her for incontinence she woke up and I asked her if she was still hurting and she said she was. When (Employee #20) picked up her right foot to put her sock on, she grabbed her right leg and grimaced. We asked her where she was hurting and again She said 'All over'. We checked her all over real good while dressing her and found no abrasions or bruised other than two small faint ones on her right buttocks... (Employee #20) gave her some Tylenol. While sitting there, she fell back asleep but still had a pained look on her face. ... "" 01/01/11 - Employee #32 - ""On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. (Resident's name) did not stand and was watched closely watched in her wheelchair. On December 30, (Resident's name) was up in her wheelchair & made no attempts to get up that day."" 01/01/11 - Employee #104 (NA) - ""... was in bed complaining of leg pain, after, getting up she complained more to the point of not eating and crying. ..."" Employee #104 also noted the resident could not stand on her leg. 01/02/11 - Employee #32 - ""On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. ..."" 01/02/11, day shift, Employee #26 (NA) - ""... On Sunday 1-2-11 she still complained of being in pain all day long."" 01/02/11 - Employee #104 (NA) - ""... Cryed in bed and after getting in wheelchair. She was so miserable and crying in pain we put her in the recliner in the common area. She could not stand on her leg either day."" 01/02/11 - days / evenings, Employee #111 (LPN) - ""... Resident slept until right before lunch in the recliner chair. When (Resident's name) woke up, she was tearful, but when I asked her if she was hurting, she said 'no'. I asked her in several different ways if she was hurting, but she kept denying pain and stated, 'I just don't know where I am or what I'm supposed to do.' ... Throughout the shift, I administered Tylenol to (Resident) as ordered just to be sure that she wasn't experiencing pain. The Tylenol did not affect her tearfulness."" She also noted she had tried to contact Dr. (name) at 1400 (2:00 p.m.), but contact was not made until 1830 (6:30 p.m.) She told him about the resident's ""persistent tearfulness and guarding when awake. ..."" An x-ray was ordered and at approximately 2330 (11:30 p.m.) received x-ray reports that the resident had a displaced [MEDICAL CONDITION] hip, and she was transferred to the hospital. 01/02/11, evenings / nights - Employee #37 - ""I came back on at 3pm, (Resident's name) was asleep in beige recliner. She slept most of the evening but kept her hand on her right leg. She was gotten up and toileted before dinner, took 2 of us just like the night before. She ate (was fed) very little dinner saying she was tired of hurting and had tears in her eyes. This aide did not put her to bed but as I was putting her roommate to bed, she was lying in bed and crying, saying, 'I can't take this pain anymore'. After finishing with her roommate, I checked on her, tried to reposition her to make her a little more comfortable but nothing really helped. After that we kept making 15 min - ? hr checks on her until she was sent out."" 01/02/11, night shift - Employee #20 (LPN) - ""I came back in Sun night (1-2-11) for 11-7 shift. The nurse (nurse's name) that worked that day + evening gave report on (Resident's name). She said that she had got a order for [MEDICATION NAME]. I received a phone call about the x-rays and that (Resident's name) (R) hip was broken. ..."" The resident was sent out to the hospital. -- 3. The physician's progress note for 12/31/10 included, ""C/O pain (R) thigh & knee area. (Symbol of 'no') knee swelling. Able to extend knee. No perceptible tenderness but the pain is really hurting her/c crying, etc."" -- 4. Review of the medication administration records found she had been given Tylenol, according to the front sheet of the medication administration records (MAR) as follows: on 12/31/10 at 2:00 p.m. and 9:00 p.m.; on 01/01/11 at 3:30 a.m., 9:30 a.m., and 5:00 p.m.; and on 01/02/11 at 6:00 a.m., 9:00 a.m., and 3:00 p.m. This was a total of eight (8) doses. - The back of the MARs indicated the resident received Tylenol for pain as follows: On 12/31/10: - At 2:00 p.m. for ""C/O pain (R) knee/leg"", with no results documented - At 9:00 p.m. for ""C/O pain (R) knee/leg"", with the results charted as ""(-)"" (a minus sign that was circled) On 01/01/11: - At 3:30 a.m. for ""C/O (R) knee & leg pain, with the results charted as ""(-)"" - At 9:30 a.m. for ""C/O (R) leg/knee pain"", with no results charted - At 5:00 p.m. for ""C/O (R) leg/knee pain"", with no results charted On 01/02/11: - At 6:00 a.m. for ""C/O (R) leg pain"", with the results charted as ""(-)"" This was a total of six (6) doses. - On 01/24/11 at 6:05 p.m., Employee #29 (LPN) was asked about the minus signs. She said, ""If you don't get a plus you need to do something else."" Review of the nursing entries and MARs, regarding the administration of Tylenol, found it was given regardless of the severity of the pain. The pain was not rated consistently, and there were only three (3) of eight (8) doses that had been evaluated for effectiveness. The physician's orders [REDACTED]."" However, it was not noted the resident complained of a headache during this time. Tylenol is for mild to moderate pain. Although the resident was noted to have severe pain at times, there was no evidence staff contacted the physician for an [MEDICATION NAME] that would control the resident's pain. According to the controlled medication book, the [MEDICATION NAME] had arrived at 11:00 p.m. on 01/02/11. No doses were signed out in the book, nor charted on the Medication Administration Record, [REDACTED] -- b) Evidence of the facility's identification and correction of the deficient practice related to pain management 1. On 01/24/11 at approximately 6:15 p.m., the director of nursing (DON) provided copies of two (2) ""One on One Education"" forms. One (1), date 01/07/11, was for Employee #56 (an RN). The concern was ""not adequately assessing resident for pain or pain relief. Pain assessment and change of condition not initiated /c (with) new onset of pain."" The corrective action needed to remedy concerns: ""Must ensure that all resident are as free of pain as possible. Must complete pain assessment & change of condition /c any new onset of pain. Must notify physician of resident need and obtain adequate medication."" Another education form was completed on 01/07/11 for Employee #113 (an LPN). It had essentially the same information as the other. As the DON pointed out, the RN was responsible for assessing resident and the LPN was responsible for evaluation of the resident. The DON said another form had been completed for another nurse, but she was unable to locate that document prior to exit. -- 2. The DON also provided a copy of an in-service on ""Pain Management"" that had been provided to staff. This addressed evaluation of pain, notification of the physician, continued assessment of the resident for the presence of pain - either verbal or observation of non-verbal indicators, documentation of evaluations, care planning, assessment and documentation of the effectiveness of pain interventions, notification of the physician when pain medications were ineffective, and so on. -- 3. The administration of pain medications to Resident #50 after her return from the hospital was reviewed. Page 204 of the ""Controlled Substances Book"" indicated she received [MEDICATION NAME] 5/500 at 9:00 p.m. on 01/13/11. She received a total of three (3) doses of [MEDICATION NAME] at this dosage. Page 206 indicated she received [MEDICATION NAME] 10/500 for two (2) doses on 01/19/11 and five (5) doses on 01/20/11, then it was discontinued. Page 211 of the book indicated she had been started on [MEDICATION NAME] 12 mcg patches. These had been applied on 01/21/11 and 01/24/11. Page 212 indicated the resident had been started on [MEDICATION NAME] 5/325. She received four (4) doses on 01/21/11, four (4) doses on 01/22/11, two (2) doses on 01/23/11, and two (2) on 01/24/11. -- 4. The controlled substances book was randomly reviewed with regard to the administration of [MEDICATION NAME]. No issues related to usage were noted. -- 5. The resident was observed in the common area of Mary's Garden on 01/25/11, after lunch. She did not appear to be in pain or exhibit non-verbal indicators of pain. Other residents in the common area were randomly observed and none demonstrated any indicators of pain. General observational tours of the other units did not find any visual or auditory indicators of residents experiencing pain or discomfort. -- 6. The records of Residents #41 and #53, both had sustained falls, were reviewed. No issues related to pain management were found. -- 7. On 01/25/11 at 12:42 p.m., the DON said they had done pain assessments on everyone in the building after the occurrence with Resident #50. -- 8. Based on the staff interviews, observations, review of medical records, and review of other facility documents, it was determined the had identified the deficits in care provided to Resident #50 with respect to assessment of her pain, relevant documentation, administration of [MEDICATION NAME], evaluation of the efficacy of [MEDICATION NAME], notification of the physician, and other related aspects of pain management. Staff had been provided with needed training and those involved had been given one-on-one educational counseling. It was therefore determined the facility had identified the deficient practice and implemented corrective actions to prevent recurrence. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at ?483.25 - Quality of Care.",2014-03-01
11442,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2010-11-04,353,F,,,UZ0K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility-generated Form CMS-672 (Resident Census and Conditions of Residents) and facility-generated Form CMS-802 (Roster / Sample Matrix), review of the nursing staffing calculation worksheet completed by the facility for the time period of 10/10/10 through 10/23/10, review of payroll records, nursing staff postings, and assignment sheets, review of resident council meeting minutes for 10/18/10, random observations, family interview, and staff interview, the facility failed to provide sufficient direct care nursing staff on the 7:00 a.m. to 3:00 p.m. (7-3) shift to meet the assessed care needs of dependent residents and to also answer call lights in a timely manner. This practice has the potential to affect all residents in this facility. Facility census: 94. Findings include: a) According to the CMS-802 (Roster / Sample Matrix) generated by the facility from data collected through the minimum data set (MDS) assessments, there were ninety-four (94) residents living there at the time of this investigation. b) According to the CMS-672 generated by the facility from data collected through the MDS assessments: For bathing - zero (0) residents were independent, seventy-five (75) residents required the assistance of one (1) or two (2) staff, and nineteen (19) residents were totally dependent. For dressing - four (4) were independent, sixty-eight (68) residents required the assistance of one (1) or two (2) staff, and twenty-two (22) residents were totally dependent. For transferring - five (5) were independent, seventy-four (74) residents required the assistance of one (1) or two (2) staff, and fifteen (15) residents were totally dependent. For toilet use - four (4) were independent, sixty-seven (67) residents required the assistance of one (1) or two (2) staff, and twenty-three (23) residents were totally dependent. For eating - twelve (12) were independent, eighty (80) residents required the assistance of one (1) or two (2) staff, and two (2) residents were totally dependent. For bowel and bladder status, six (6) residents had urinary catheters, fifty-three (53) residents were incontinent of bladder, and thirty-eight (38) residents were incontinent of bowel. For mobility, one (1) resident was bedfast all or most of the time, fifty-five (55) were in a chair most of the time, two (2) were independently ambulatory, and thirty-six (36) ambulated with assistance or an assistive device. For skin integrity, forty-nine (49) received preventive skin care. c) Review of the facility's resident council meeting minutes for 10/18/10 revealed that residents on both wings expressed concerns that their call lights aren ' t answered in a timely manner. They stated this happens on all shifts. Review of the facility ' s resident council meeting minutes of 9/20/10 revealed that there were complaints voiced that staff would turn off call lights before their needs are met, and also that staff needs to respond to call lights instead of just walking by them. d) During random observations on 11/1/10, it was observed that the call light for room [ROOM NUMBER] was lit from 1:30 p.m. An audible alarm monitor began sounding at 1:32 p.m. The resident was observed walking from the bathroom to her bed. When she got into the bed, the alarm stopped sounding. The call light remained on. No staff intervened until 1:42 p.m. It was also observed that the call light in room [ROOM NUMBER] was lit from 3:52 p.m. until staff responded at 4:07 p.m. Two (2) staff members walked by the room, without responding to the call light. During a random observation on 11/2/10, the call light in room [ROOM NUMBER] was lit from 2:41 p.m. until staff intervened at 3:03 p.m. During random observations on 11/3/10, the call light in room [ROOM NUMBER] was lit from 9:08 a.m. until 9:23 a.m. It was then lit again from 9:35 a.m. until 9:48 a.m. At 9:48 a.m., facility LPN, employee #E99 walked to another hall and instructed a nursing assistant to go attend to the call light. The nursing assistant was heard to state, "" I ' ll get it, but we really need two people on this hall. "" On 11/3/10 at 9:52 a.m., when LPN #E99 was asked about the delays in responding to call lights, and whether she felt there was adequate staff, she replied, "" To be honest, no. There are a lot of two-person assists on this wing. "" In another brief conversation at 10:35 a.m., she stated that she feels the staff is really trying to attend to all the residents ' needs, but they just are not able to. e) When interviewed by telephone on 11/2/10 at 10:15 a.m., the complainant, who requested confidentiality stated that there is not enough staff to get the job done, causing unintentional neglect of the residents by the nursing assistants who are not able to attend to their needs in a timely manner. She felt that this was the case on all shifts, although she was most concerned with the day shift. f) The daughter of resident #8 was interviewed on 11/2/10 at 2:30 p.m. She stated that there is not sufficient staff to meet the residents ' needs. She feels this is true on all shifts. She stated that call lights are on "" for a long, long, time. "" She has observed this with her mother ' s light and with other residents as well. She stated that residents are often wet or soiled because there is not enough staff to provide adequate care for them. She related she is concerned that residents may fall trying to get up and do for themselves when staff does not respond for long periods of time. g) Resident #60, who is an [AGE] year old woman that has resided in the facility since 10/22/04, was interviewed on 11/2/10, immediately after the observation that it took over twenty (20) minutes for her call light to be answered, stated that it always takes a long, long time. She said that this instance was better than most. She sometimes has to holler for them or they never come at all. She stated "" It makes them mad, but I can ' t help it. "" Resident #13, who is a [AGE] year old woman that has resided in the facility since 9/18/90, was interviewed on 11/3/10 at 10:00 a.m. She was asked if she felt there was sufficient staff in the facility to meet the residents ' needs. She replied "" No, there is not enough. "" She stated she just came out of the bathroom, and that she had to wait in there for twenty (20) minutes. She stated it has been like that ever since the change of ownership. She stated "" I have seen them walk right by and ignore lights. "" She said she has sat in the bathroom for an hour more than once. She stated that she has complained many times, but it has done no good. h) On 11/1/10 at 3:30 p.m., facility administrator, employee #E147 provided a staffing calculation worksheet for the most recent payroll period of 10/10/10 - 10/23/10. The staffing on 7-3 shift ranged from a low of 13.5 nursing staff on 10/11/10 to a high of 19 on 10/21/10. The average total 7-3 nursing staff for the period was 15.5. i) During an interview on 11/2/10 at 2:09 p.m. facility administrator, employee #E147 reported that staffing was adjusted for census. The general budgeted staffing levels were from 2.89 to 2.92 hours per patient per day (PPD). With a census of 94 the staffing would therefore range from 271.66 to 274.48 hours. The total nursing hours on the staffing calculation worksheet ranged from a low of 246.25 on 10/14/10 to a high of 323.5 on 10/21/10. The average total nursing staff hours for the period was 270.0. During an interview on 1/3/10 at 11:20 a.m., facility director of nursing (DON) stated that although the staffing may be adjusted for census or also at times for acuity, the usual staffing is four (4) nursing assistants and three (3) licensed nurses for each wing, for a total of eight (8) nursing assistants and six (6) licensed nurses. j) During an interview on 11/4/10 at 9:05 a.m., the facility director of nursing (DON) provided call light audit information for 10/10. She stated that the audits were to be compiled for quality assurance study in November, but that the information was not yet summarized for that purpose. Each form was found to contain fields for entry of date, room, time light went on, time light was answered, and signature. A review of the audit sheets found they covered the period of 10/12/10 to 10/31/10 as follows: 10/12/10 5 audits done, 10/13/10 2 audits done, 10/14/10 no audits done, 10/15/10 5 audits done, 10/16/10 4 audits done, 10/17/10 no audits done, 10/18/10 3 audits done, 10/19/10 1 audit done, 10/20/10 13 audits done, 10/21/10 9 audits done, 10/22/10 2 audits done, 10/23/10 11 audits done, 10/24/10 5 audits done, 10/25/10 11 audits done, 10/26/10 8 audits done, 10/27/10 9 audits done, 10/28/10 7 audits done, 10/29/10 8 audits done, 10/30/10 8 audits done, 10/31/10 7 audits done. This represents six (6) call lights timed each day. An interview was conducted with "" A "" wing facility registered nurse (RN), employee #E116, on 11/4/10 at 9:15 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. She stated that if it goes too long, she answers it herself, because she doesn ' t want the resident to wait too long. An interview was conducted with "" B "" wing facility registered nurse (RN), employee #E47, on 11/4/10 at 9:22 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. Each nurse is to do two (2) audits per shift. She stated that if the light is unanswered for ten (10) minutes, she answers it herself. k) Review of the nursing staffing on 11/1/10 and on the staffing calculation worksheet (for the time period of 10/10/10 to 10/23/10) revealed that, while the facility met the State-mandated minimum of 2.25 hours of direct nursing care per resident per day, the staffing levels deployed on the 7-3 shift on 11/1/10 were determined to be inadequate to meet the assessed care needs of all 94 of the facility's residents and also allow staff to answer call lights in a timely manner.",2014-03-01
11443,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,156,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to inform rights of their rights by: (a) failing to post the names and current contact information for all pertinent State client advocacy groups, (b) failing to provide accurate appeals information for one (1) of thirty-nine (39) Stage II sample residents, and (c) failing to provide a liability notice to one (1) of thirty-nine (39) Stage II sample residents when Medicare-covered skilled services were discontinued. Resident identifiers: #139 and #2. Facility census: 129. Findings include: a) On 05/11/11 at 11:00 a.m., the surveyor went with the administrator (Employee #200) and the social worker (Employee #129) to find where the required agency postings were located in the facility. It was observed that addresses were not posted at the time. A poster with agency addresses had been in the administrator's office in a framed poster. She said they were taken down so she could change the address of the state agency. The current state agency address will be a year old in July 2011. On 12:46 p.m. on 05/11/11, the administrator presented the surveyors with additional pamphlets, signs, forms, etc. with the advocacy groups names, address and phone numbers listed on it. These were not available at the time of survey. b) Resident #139 Record review revealed that, on 03/17/11, Resident #139 received conflicting notification of transfer / discharge related to which State agency to contact for appeals related to his discharge from the facility to home. Page 2 of the ""Notification of Transfer / Discharge"" listed several State agencies to which a resident may appeal the transfer / discharge decision, although the only correct State agency was the Office of Inspector General's Board of Review. During an interview on the early afternoon of 05/03/11, after request was made for a copy of the information provided to residents upon transfer or discharge, the administrator reported the 2-page ""Notification of Transfer / Discharge"" was not the current form and staff should not be using it. c) Resident #2 A review of this resident's discharge date from Medicare-covered skilled services, during an interview with the business office manager (Employee #147) on 05/10/11 at 4:00 p.m., found the resident was discharged on [DATE], when he used up one hundred (100) days of Medicare Part A services and then returned to Medicaid as the primary payor for his care at the facility. The facility's log of Medicare liability notices was reviewed at this time, and Resident #2's name was not on the log. Employee #147 reported that copies were made of all notices, but there was none available for this resident. Review of the Beneficiary Notices Initiative Summary with Employee #147 found no evidence that Resident #2 was notified that his Medicare Part A days had exhausted. .",2014-03-01
11444,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,159,D,,,1I0H11,". Based on record review and staff interview, the facility failed to obtain written authorization to manage personal funds for two (2) of three (3) residents reviewed. The facility managed funds for these residents but had no written authorization to do so. Additionally, based on observation of the official posting of the availability of resident funds, residents did not have access to petty cash on an ongoing basis. Resident identifiers: #148 and #90. Facility census: 129. Findings include: a) Resident #148 Review of personal funds, on 05/10/11 at 2:30 p.m., with the business office manager (Employee #147) revealed this resident had $91.16 in the resident trust fund account. Review of authorizations to manage resident funds revealed a signed resident trust authorization. It had an ""x"" beside an option indicating the resident did not want the facility to manage her personal funds. -- b) Resident #90 Review of personal funds, with Employee #147 on 05/10/11 at 2:30 p.m., revealed this resident had $9.54 in the resident trust fund account. Review of authorizations to manage resident funds revealed this resident signed a resident trust authorization on 02/01/08. It had an ""x"" beside the option indicating the resident did not want the facility to manage his personal funds. -- c) During the initial tour, on 05/02/11 at 3:00 p.m., a framed notice regarding resident funds was observed outside the business office, stating the times the resident's funds were available at the business office and times the funds were available at the East nursing station. Based on the information on this sign, resident funds were not available from 5:00 a.m. to 8:00 a.m. Monday through Friday, or from 8:00 a.m. to 10:00 a.m. on Saturday and Sunday. During an interview with Employee #147 on 05/10/11 at 2:30 p.m., an inquiry was made regarding when funds were available to the residents. Employee #147 stated the residents had access to their funds twenty-four (24) hours a day, seven (7) days a week. She also stated there was a notice posted to this effect. At that time, Employee #147 was informed the official posting of funds availability did not indicate funds were available twenty-four (24) hours a day, seven (7) days a week. .",2014-03-01
11445,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,225,E,,,1I0H11,". Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to complete statewide criminal background checks for five (5) of five (5) sampled employees, in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The ""Initial Screening of Prospective Applicants"" policy stated, ""Provider will conduct criminal background checks on all perspective applicants..."", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was completed. However, this printout did not include evidence as to how the background checks were completed. .",2014-03-01
11446,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,226,E,,,1I0H11,". Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to develop and implement a policy and procedure that ensured statewide criminal background checks were completed on new hires, to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The ""Initial Screening of Prospective Applicants"" policy stated, ""Provider will conduct criminal background checks on all perspective applicants..."", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was completed. However, this printout did not include evidence as to how the background checks were completed. .",2014-03-01
11447,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,241,D,,,1I0H11,". Based on observation, the facility failed to ensure privacy during a visit for one (1) of thirty-nine (39) Stage II sample residents. A staff member entered the resident's room without first knocking or asking permission to enter the room. At that time, the resident had a visitor. Resident identifier: #173. Facility census: 129. Findings include: a) Resident #173 On 05/03/11 at 3:10 p.m., a member of the survey team was conducting a Stage I interview with this resident. Without first knocking and/or asking permission to enter the room, Employee #136 (a licensed practical nurse - LPN) came into the room with a rolling blood pressure cart. Employee #136 walked over to the resident and told her she was going to take her blood pressure. While she was taking the resident's blood pressure, Employee #136 looked over at the resident's visitor (a surveyor) and asked the visitor (surveyor) if she was ""doing a diary"" for the resident. .",2014-03-01
11448,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,242,D,,,1I0H11,". Based on family interview, observation, staff interview, and review of the resident tray cards, the facility failed to ensure two (2) of thirty-nine (39) Stage II sample residents had the right to make choices about aspects of life in the facility that are significant to the residents. Resident #63's family complained that Resident #63 was wearing clothing that was not hers and the resident's closet contained clothing that did not belong to the resident. Resident #90's food preferences were not honored. Facility census: 129. Findings include: a) Resident #63 During an interview on 05/03/11 at 3:49 p.m., Resident #63's family reported finding the resident wearing clothing that did not belong to her and looked ""terrible"". The family member stated they complained about this to a staff member and were given a form to fill out. The resident was given clothing from other residents, and she wore ""things that are not hers"". The family member reported finding the resident wearing other residents' clothing even after having complained to the facility about the matter. Observation of the resident's closet, with a licensed practical nurse (LPN - Employee #177) on 05/05/11 at 4:15 p.m., found a 2-piece outfit on a hanger with another resident's name in both pieces of the clothing. Also found folded up in the bottom of the closet were two (2) brassieres that had other residents' names on them. Review of the nursing notes found an entry dated 05/07/11 at 3:00 p.m., stating, ""Spoke to ... concerning closet and rummaging of a roommate. Gave consent to apply a safety lock to assist with the rummaging behavior (sic) of other peers."" -- b) Resident #90 Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident stated he was particularly ""upset"" about getting gravy. He said it makes him sick, and he got it ""last night"". The resident stated he could not understand why he always got gravy, because it was noted as a dislike on his tray slip. Review of the resident's dietary progress notes revealed nothing regarding food preferences. During the morning of 05/05/11, the dietary manager (DM - Employee #21) was asked if food preferences were documented somewhere else. At 10:45 a.m. on 05/05/11, the DM provided a list of Resident #90's food preferences which had been completed on 04/20/11. It indicated gravy as a dislike. On 05/05/11 at 1:30 p.m., an interview was conducted with the resident, with the DM present. The resident stated he was still receiving gravy and that he ""got gravy again last night"". The resident stated his sister was visiting at the time his meal was served, and she ""scraped the gravy off into a cup"". A telephone interview with the resident's sister, at 2:40 p.m. on 05/05/11, confirmed she was visiting the resident at noon on 05/04/11 and the resident was served gravy. She stated she ""scraped it off into a cup"". The resident's sister said she looked at the ""slip"" with his diet on it, and it said ""no gravy"". .",2014-03-01
11449,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,252,E,,,1I0H11,". Based on observation and staff interview, the facility failed to provide a homelike environment during resident dining in the North dining room. Staff walked in and out of the dining room, to an office at the back of the dining room, numerous times during the meals. This was not a homelike environment which de-emphasized the institutional character of the setting. This practice had the potential to affect more than an isolated number of residents who had their meals daily in the North dining room. Facility census: 129. Findings include: a) During observation of resident dining in the North dining room during the evening meal on 05/02/11, several facility staff members were observed continuously coming and going through the dining room into a room at end of the dining room. This gave the appearance that resident dining was not nearly as important as whatever staff members were doing in the room at the end of the dining room. The dining room was an avenue to an office, instead of a homelike area for meals. On 05/04/11, meal service in the North dining room was again observed. Between 12:00 p.m. and 12:20 p.m., a period of twenty (20) minutes, staff members went through the dining room into the room at the back eleven (11) times, and from that room through the dining room nine (9) times. Later on 05/04/11, it was learned the doorway at the end of the dining room led to the office shared by the scheduler and staff development. This doorway also led to a conference room. At 1:00 p.m. on 05/10/11, an interview was conducted with the administrator (Employee #200), who confirmed this was not creating a homelike environment which de-emphasized the institutional character of the setting. .",2014-03-01
11450,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,253,E,,,1I0H11,". Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable resident environment. Prompt housekeeping services were not provided to address a strong, persistent, unpleasant odor of urine in the room of Resident #72, one (1) of thirty-nine (39) Stage II sample residents. Routine maintenance services were not provided to ensure the door to the central shower room on the North unit and the wooden handrails in the corridors on the North, East, and Alzheimer's units were free of damage that prevented the surfaces from being able to be effectively cleaned / sanitized. Resident identifier: #72. Facility census: 129. Findings include: a) Resident #72 Observation, on 05/03/11 at 3:09 p.m., revealed the presence of a strong urine odor in the hallway outside Resident #72's room. Numerous staff was observed walking past the room without intervention for the odor as follows: - At 3:10 p.m., an unidentified aide; - At 3:11 p.m., a nurse (Employee #18); - At 3:12 p.m., a nurse aide (Employee #52); - At 3:13 p.m., a nurse (Employee #85); - At 3:14 p.m., an unidentified housekeeping employee; - At 3:15 p.m., Employee #85 and the housekeeping employee; and - At 3:18 p.m., Employee #85. During an interview with the assistant director of nursing (ADON - Employee #112) on 05/03/11 at 3:22 p.m., she acknowledged the presence of the strong urine smell in Resident #72's room and in the hallway outside his door. A restorative aide (Employee #34) emptied Resident #72's urinary drainage bag, but no odor could be detected in the plastic receptacle into which the urine was drained or in the bathroom when the urine was emptied into the commode; she said the odor may have come from the urinary catheter bag having drained ""urine onto the floor and the smell seeped into the flooring (laminate)"" at some previous point in time, and she agreed the floor on the left side of his bed was a little sticky. The restorative aide checked and did not find any evidence of urinary incontinence by either Resident #72 or his roommate at this time. As Resident #72 was wheeled out of the room in his wheelchair by Employee #34 on 05/03/11 at 3:53 p.m., a strong smell of urine was detected by two (2) surveyors as he passed by in his wheelchair. During an interview with a nurse (Employee #18) on 05/03/11 at 3:53 p.m., she said she changed the urinary drainage bag and sprayed the floor and the wheelchair; she also said Resident #72 received a shower this morning by the hospice aide. Soon after, housekeeping staff mopped the floor in his room. Observation of Resident #72's room, on the morning of 05/04/11, found a slight odor of urine was present; housekeeping had mopped the floor earlier this morning. Observation of Resident #72's room, on 05/05/11 at 11:20 a.m., found there was no odor of urine detected. During an interview with Employee #85 at this time, she said she believed the urine odor came from his socks, where he had stepped onto the floor which had the urine odor. On 05/05/11 at 2:00 p.m., the administrator was informed about the strong urine odor related to Resident #72 and his room, with no further information obtained. -- b) Observations of the safety of handrails and other environmental issues were conducted in the mid afternoon of 05/10/11 with the following concerns identified: - On the East wing corridor from rooms 104 to 106 and room 106 to 108, the wooden handrailing had some rough spots that needed repair. Wooden handrailing in the corridor between rooms 109 and 110 was found to be in the same condition. - On the North wind corridor, handrails near rooms 335 and 337 were rough with areas that could catch clothing, etc. on them, and the handrail outside room 345 had a rough area noted with splinters. - Observations of Alzheimer's unit found the handrailing in the corridor outside of room 202 to be badly splintered. These issues were discussed with the maintenance supervisor (Employee #144) on the afternoon of 05/10/11. He reported there was a plan in place through which the handrails were being replaced and/or sanded and repaired. These issues were also discussed with the administrator on the afternoon of 05/11/11. An undated document was later given to the surveyors, which stated that repairs to handrails would start in the main dining room and progress towards East hall. This was to start in March and be completed by June. There was no provision address needed repairs to rough and damaged handrails that presented safety hazards to residents in other areas of the building. -- c) Observation, at 9:15 a.m. on 05/11/11, found the main door of the central bath on the North unit to be badly scratched and banged up, making the surface not easily cleanable as well as unsightly. This issue was mentioned to the administrator during the afternoon of 05/11/11. .",2014-03-01
11451,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,279,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview, the facility failed to develop a care plan for one (1) of thirty-nine (39) Stage II sampled residents who had distinct food preferences. Resident identifier: #90. Facility census: 129. Findings include; a) Resident #90 Record review revealed this resident was admitted to the facility on [DATE]. Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident further stated it was "" not necessarily that I don ' t like them, they don ' t like me "" . During the survey, it was confirmed the resident was receiving foods which were noted as dislikes on his tray card. Review of the resident's comprehensive care plan, on the morning of 05/05/11, revealed nothing regarding food preferences and/or foods that did not "" like him "" . This was brought to the attention of the dietary manager (DM - Employee #21) at 10:45 a.m. on 05/05/11. At that time, the DM confirmed there was no care plan for the resident's food preferences. On 05/06/11, the DM provided a care plan, dated 05/06/11, related to preferences for Resident #90. It stated as the problem, ""Resident will report he receives food not on his preferences even if they were not served that day."" There were no associated goals and interventions to assure the resident's known preferences were honored and/or to assure the resident's food preferences were periodically updated. Additionally, the problem, as stated, was not the problem expressed by the resident. The resident was getting foods he previously told the facility he did not like and that did not "" like him "" . His newly written care plan did not address this problem at all. On 05/10/11 at 4:55 p.m., an interview regarding this care plan was conducted with the director of nursing (DON - Employee #49). The DON agreed a care plan for the resident to report to staff was not a sufficient means of addressing this resident's needs. On 05/12/2011 an additional care plan problem was instituted for this resident which stated "" resident states certain foods such as gravy give him diarrhea. Has multiple food dislikes "" . This care plan included nursing staff in assuring the resident did not receive foods that were on his dislike list. .",2014-03-01
11452,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,280,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plan for one (1) of thirty-nine (39) Stage II sampled residents to address her low [MEDICATION NAME] level. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, ""... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow pointing up) Protein (renal). ..."" Subsequent entries, made by the dietary manager on 01/06/11, 01/21/11, 02/21/11, and 03/21/11, also noted the provision of 1-1/2 protein with the resident's diet. On 04/29/11, the dietitian noted, ""... Labs reviewed - 4/26 Alb ([MEDICATION NAME]) 2.5 - moderately depleted visceral protein stores - likely r/t (related to) [MEDICAL CONDITION] / diuretic tx (treatment) ..."" -- 3. Review of the March 2011 recapitulation of physician orders [REDACTED]."" (The word ""protein"" was handwritten, while the rest of the order was typed.) Review of the May 2011 recapitulation of physician's orders [REDACTED]. -- 4. Interview with the dietary manager (Employee #21), on 05/05/11 at 9:56 a.m., revealed that ""1-1/2 protein"" meant the resident was to receive 1-1/2 sized portions of each protein served at each meal. However, the dietary manager stated Resident #82's order for extra protein was not carried over; therefore, this resident had not been receiving the extra protein diet as prescribed by the physician. When asked, Employee #21 stated the resident's diet was for regular consistency, consistent carbohydrate, no added salt, low potassium, with fluid restrictions of 2200 cc per day. She said there was nothing special about the protein for her diet, and Resident #82 ""gets what everybody else gets"" in the way of protein. -- 5. During an interview on 05/05/11 at 10:20 a.m., the dietician agreed that the ""1-1/2 protein"" ordered for Resident #82 meant that, with each protein item served at each meal, the resident was to receive a 1-1/2 portioned size. According to the dietician, the first carry-over of physician's orders [REDACTED]. The dietician said that, upon admission in December 2010, Resident #82 was on a regular diet, and she calculated Resident #82's daily protein needs of 44 - 55 grams per day based on her ideal body weight range of 86 - 106 pounds, and not on her admission weight of 194 pounds. The dietician said Resident #82 received about 90 grams of protein per day with the diet now ordered and the ""1-1/2"" portion size would equal 135 grams of protein per day. -- 6. Resident #82's most current care plan, which was last reviewed by the interdisciplinary team on 03/30/11 (with additional handwritten entries added after that date), included the following problem statements related to nutrition (quoted as written): - ""111 - therapeutic diet - wt (weight) fluctuates due to [MEDICAL CONDITION] - wt loss desired"" (dated 01/12/11) - ""Non-compliant /c (with) diet & fluid rest (restriction)"" (dated 04/28/11) - ""181 - Risk for skin breakdown related to diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]"" (dated 01/06/11) - ""[MEDICAL CONDITION]"" (dated 03/30/11) None of the above problems, nor any of the other problems on the comprehensive care plan, included an intervention to provide the resident with addition protein. .",2014-03-01
11453,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,323,E,,,1I0H11,". Based on observation, review of material safety data information, and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as possible. A hazardous cleaning product was left in a resident room, hazardous cleaning products were stored in an unlocked cabinet in the North shower room, and wooden handrailing in the corridors had splintered and/or rough areas, creating a potential for resident injury. These practices had the potential to affect more than an isolated number of residents. Facility census: 129 Findings include: a) On 05/03/11 at 2:18 p.m., a cleaning product in a spray bottle was observed in room 311. The name of the product was ""T B QUAT"". The bottle contained directives to ""keep out of reach of children"" and noted the product was a ""hazard to humans and domestic animals"". Review of the material safety data sheet for the product revealed the following identified hazards: - ""Corrosive to eyes. Will cause eye burns, Permanent eye damage or blindness may result without immediate first aid treatment. Harmful or fatal if swallowed."" - For ingestion: ""May cause nausea, vomiting, and swelling of the larynx, and skeletal muscle paralysis affecting ability to breath, circulatory shock, and convulsions."" - ""Inhalation of mists may cause irritation to the nose, throat, and mucous membranes. Tissue damage and Pulmonary irritation. Severity depends upon degree of exposure."" - For skin contact: ""Contact may cause mild to severe irritation, drying, and dermatitis. Health effects depend on degree of exposure."" At 2:35 p.m. on 05/03/11, the director of nursing (DON - Employee #49) was asked to point out where the product should be stored. The DON went to the North shower room and pointed out the cabinet in which the products were stored. The cabinet had an unlocked lock on the doors. Upon inquiry, the DON confirmed the cabinet was supposed to be locked. -- b) Observations of the safety of handrails and other environmental issues were conducted in the mid afternoon of 05/10/11 with the following concerns identified: - On the East wing corridor from rooms 104 to 106 and room 106 to 108, the wooden handrailing had some rough spots that needed repair. Wooden handrailing in the corridor between rooms 109 and 110 was found to be in the same condition. - On the North wind corridor, handrails near rooms 335 and 337 were rough with areas that could catch clothing, etc. on them, and the handrail outside room 345 had a rough area noted with splinters. - Observations of Alzheimer's unit found the handrailing in the corridor outside of room 202 to be badly splintered. These issues were discussed with the maintenance supervisor (Employee #144) on the afternoon of 05/10/11. He reported there was a plan in place through which the handrails were being replaced and/or sanded and repaired. These issues were also discussed with the administrator on the afternoon of 05/11/11. An undated document was later given to the surveyors, which stated that repairs to handrails would start in the main dining room and progress towards East hall. This was to start in March and be completed by June. There was no provision address repairs to rough and damaged handrails that presented safety hazards to residents in other areas of the building. .",2014-03-01
11454,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,325,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a physician-ordered therapeutic to one (1) of thirty-nine (39) Stage II sample residents in an effort to maintain acceptable parameters of nutritional status such as protein levels. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Her most current care plan, which was last reviewed by the interdisciplinary team on 03/30/11 (with additional handwritten entries added after that date), included the following problem statements related to nutrition (quoted as written): - ""111 - therapeutic diet - wt (weight) fluctuates due to [MEDICAL CONDITION] - wt loss desired"" (dated 01/12/11) - ""Non-compliant /c (with) diet & fluid rest (restriction)"" (dated 04/28/11) - ""181 - Risk for skin breakdown related to diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]"" (dated 01/06/11) - ""[MEDICAL CONDITION]"" (dated 03/30/11) None of the above problems, nor any of the other problems on the comprehensive care plan, included an intervention to provide the resident with addition protein. -- 3. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, ""... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow pointing up) Protein (renal). ..."" Subsequent entries, made by the dietary manager on 01/06/11, 01/21/11, 02/21/11, and 03/21/11, also noted the provision of 1-1/2 protein with the resident's diet. On 04/29/11, the dietitian noted, ""... Labs reviewed - 4/26 Alb ([MEDICATION NAME]) 2.5 - moderately depleted visceral protein stores - likely r/t (related to) [MEDICAL CONDITION] / diuretic tx (treatment) ..."" -- 4. Review of the March 2011 recapitulation of physician orders [REDACTED]."" (The word ""protein"" was handwritten, while the rest of the order was typed.) Review of the May 2011 recapitulation of physician's orders [REDACTED]. -- 5. Interview with the dietary manager (Employee #21), on 05/05/11 at 9:56 a.m., revealed that ""1-1/2 protein"" meant the resident was to receive 1-1/2 sized portions of each protein served at each meal. However, the dietary manager stated Resident #82's order for extra protein was not carried over; therefore, this resident had not been receiving the extra protein diet as prescribed by the physician. When asked, Employee #21 stated the resident's diet was for regular consistency, consistent carbohydrate, no added salt, low potassium, with fluid restrictions of 2200 cc per day. She said there was nothing special about the protein for her diet, and Resident #82 ""gets what everybody else gets"" in the way of protein. -- 6. During an interview on 05/05/11 at 10:20 a.m., the dietician agreed that the ""1-1/2 protein"" ordered for Resident #82 meant that, with each protein item served at each meal, the resident was to receive a 1-1/2 portioned size. According to the dietician, the first carry-over of physician's orders [REDACTED]. The dietician said that, upon admission in December 2010, Resident #82 was on a regular diet, and she calculated Resident #82's daily protein needs of 44 - 55 grams per day based on her ideal body weight range of 86 - 106 pounds, and not on her admission weight of 194 pounds. The dietician said Resident #82 received about 90 grams of protein per day with the diet now ordered and the ""1-1/2"" portion size would equal 135 grams of protein per day. -- 7. During an interview with the administrator on 05/05/11 at approximately 1:30 p.m., these findings were discussed, and she agreed there was no pre-[MEDICATION NAME] in Resident #82's medical record. -- 8. Further record review revealed a physician's telephone order, dated 05/09/11 at 7:45 p.m., to discontinue the 1-1/2 protein portions. .",2014-03-01
11455,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,356,C,,,1I0H11,". Based on observation and staff interview, the facility failed to post nursing staffing information which contained all the elements required by this regulation. In addition, the posted information was not documented in a clear, readable format. This practice had the potential to affect all facility residents, families, and guests. Facility census: 129. Findings include: a) During tour on 05/02/11 at 3:00 p.m., observation of the posted nursing staffing information found it did not differentiate between registered nurses and licensed practical nurses. Additionally, it was not documented in a clear manner that any person reviewing it could understand. The confusion associated with reading the form was confirmed by the staff scheduler (Employee #162) during an interview at 3:45 p.m. on 05/02/11. .",2014-03-01
11456,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,366,E,,,1I0H11,". Based on observation and staff interview, the facility failed to ensure staff offered food substitutes to five (5) randomly observed residents when they did not eat their entrees at the evening meal on 05/02/11. Resident identifiers: #55, #114, #13, #65, and #147. Facility census: 129. Findings include: a) Residents #55, #114, #13, #65, and #147 During the evening meal service beginning at 5:30 p.m. on 05/02/11, observation found these five (5) residents left the North dining room between 5:30 p.m. and 5:50 p.m.; none of the five (5) had eaten their entrees. Staff members were in the dining room assisting residents who required spoon feeding and other assistance; however, no one acknowledged these residents leaving, and no one offered any of them a substitute for their uneaten entrees. On 05/10/11 at 1:00 p.m., this was discussed with the administrator (ADM - Employee #200). At that time, the ADM confirmed staff should monitor residents who feed themselves, as well as those who required assistance, to assure all residents are offered substitutions as needed. .",2014-03-01
11457,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,371,F,,,1I0H11,". Part I -- Based on observation, record review, and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 129. Findings include: a) Observations of the dietary department, with the dietary manager (Employee #21) as part of the initial tour on 05/02/11 at 3:00 p.m., found large stainless steel mixing bowls were still wet when being stored and the shelf on which they were stored was wet. Review of the recent county sanitarian report, dated 02/23/11, found the dietary department was cited for not allowing pans to air dry before stacking them. b) Also found during the initial tour were the following: - Plastic containers of whole and skim milk in the walk-in refrigerator were not dated when opened, so dietary staff could determine how long each product had been opened and whether it was still safe for consumption. - Oven doors, when opened, were found to have food debris spilled across the edges and to be in need of cleaning. c) Observation of nourishment station on the North unit, on 05/10/11 at 2:40 p.m., found in the refrigerator a open / half-empty container of honey-thickened liquid that was not dated when opened. This finding was related to the dietary manager at 1:00 p.m. on 05/11/11. -- Part II -- Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Employee #39) distributing a meal tray to Resident #107 in the resident's room; while doing so, Employee #39 touched the resident's overbed table and water pitcher. Without washing hands or using hand sanitizer, Employee #39 then went to the food cart and obtained another tray, which he served to Resident #36. The employee then washed his hands before returning to the food cart to obtain another resident's meal tray for distribution. This finding was reported to the administrator at approximately 1:30 p.m. on 05/05/11. b) Employee #58 During the evening meal service on the dementia unit on 05/02/11 at 5:30 p.m., observation found a registered nurse (RN - Employee #58) washed her hands and then turned off the water faucet before obtaining a paper towel. Review of the facility's policy and procedure for hand washing (dated 01/2010) found in Section C at Item 3: ""When washing hands with soap and water, wet hands first with water, apply soap and rub hands together vigorously for at least 20 seconds (Centers for Disease Control (CDC), 2010) covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet."" The above was reviewed with the administrator at 3:30 p.m. on 05/10/11. .",2014-03-01
11458,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,425,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, a resident received a daily dose of Lisinopril (an ACE inhibitor used to treat hypertension) for five (5) consecutive days even though his record noted he was allergic to this classification of drugs, and he received one (1) of these doses after the physician discontinued the medication due to the allergy. Resident identifier: #61. Facility census: 129. Findings include: a) Resident #61 Observation during medication pass revealed Resident #61 received a dose of Lisinopril 2.5 mg at approximately 9:00 a.m. on 05/10/11. Record review revealed a physician's telephone order, dated 05/09/11 at 9:00 a.m., with clarification of orders to ""D/C (discontinue) Lisinopril - allergic to Ace Inhibitors."" Review of the medication administration record (MAR) for May 2011 revealed Resident #61 received Lisinopril 2.5 mg orally daily at 9:00 a.m. on 05/06/11, 05/07/11, 05/08/11, 05/09/11, and 05/10/11. In the ""allergies [REDACTED]. Review of the monthly recapitulation of physician's orders [REDACTED]. Also found on the monthly recap was an order for [REDACTED]. These orders were checked by a nurse (Employee #167) as attested by her signature which was dated for 05/05/11. Further review of the physician's telephone orders found an order dated 04/14/11 at 6:00 p.m., stating ""allergies [REDACTED]. During an interview with a nurse (Employee #18) on 05/10/11 at approximately 4:30 p.m., she agreed the order to stop the Lisinopril was written on 05/09/11 at 9:00 a.m., but the MAR was initialed to indicate this medication was administered by the nurse at 9:00 a.m. on 05/10/11. Employee #18 agreed the clarification order dated 05/09/11 noted the resident was allergic to ACE Inhibitors, as did both the MAR and the monthly recapitulation of physician's orders [REDACTED]. Subsequent record review found an incident report was completed on 05/10/11 at 5:00 p.m., and the physician was notified that the Lisinopril (which was discontinued on 05/09/11) was erroneously given at 9:00 a.m. 05/10/11. Actions taken included monitoring Resident #61's blood pressure and removing the Lisinopril from the medication cart; nursing staff also informed the resident of the occurrence. Record review, on 05/11/11, revealed a physician's progress note dated 05/11/11, stating Resident #61 was recently readmitted from the hospital where he was treated with Lisinopril in the hospital and at the facility without problem, and noting that his history include an ACE inhibitor allergy. The physician clarified that Resident #61 did not have an allergy to Lisinopril or to ACE inhibitors. The physician cancelled the ACE inhibitor allergy notation on his record but left the resident off of the Lisinopril. During an interview with the DON in the early morning 05/11/11, she clarified that Resident #61 actually did not have an allergy to ACE inhibitors but, by history, was noted he was not to be on ACE inhibitors because of his [DIAGNOSES REDACTED]. .",2014-03-01
11459,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,441,E,,,1I0H11,". Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #58 During the evening meal service on the dementia unit on 05/02/11 at 5:30 p.m., observation found a registered nurse (RN - Employee #58) washed her hands and then turned off the water faucet before obtaining a paper towel. Review of the facility's policy and procedure for hand washing (dated 01/2010) found in Section C at Item 3: ""When washing hands with soap and water, wet hands first with water, apply soap and rub hands together vigorously for at least 20 seconds (Centers for Disease Control (CDC), 2010) covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet."" The above was reviewed with the administrator at 3:30 p.m. on 05/10/11. b) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Employee #39) distributing a meal tray to Resident #107 in the resident's room; while doing so, Employee #39 touched the resident's overbed table and water pitcher. Without washing hands or using hand sanitizer, Employee #39 then went to the food cart and obtained another tray, which he served to Resident #36. The employee then washed his hands before returning to the food cart to obtain another resident's meal tray for distribution. This finding was reported to the administrator at approximately 1:30 p.m. on 05/05/11. .",2014-03-01
11460,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,225,E,,,FROJ11,". Based on review of facility documents, family interview, and staff interview, the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were reported and investigated in accordance with State law for three (3) of three (3) allegations reviewed. Resident identifiers: #26, #105, and #44. Facility census: 104. Findings include: a) Resident #26 Review of facility documents found that, on 09/23/10, Resident #44 complained to the social worker (Employee #88) that she had given a check received from her daughter for $150.00 to a staff member to deposit into her resident trust account. The resident further stated the check was never credited to her account. On 09/24/10, Employee #88 reached the following conclusion: ""Resident was unable to give specifics of check nor exact time and place when check was allegedly given to (staff). No evidence in place to support existence of check."" Further review found this resident's allegation of misappropriation of property had been handled as an in-house complaint and was not reported to State officials, including the State survey and certification agency, as required. Employee #88 was asked if he had called to daughter to determine whether she had provided the resident with a check for $150.00 prior to reaching this conclusion. He stated, on the afternoon of 11/17/10, he had not contacted the resident's daughter. After this prompting, Employee #88 contacted the resident's daughter and determined the daughter had sent the resident a check for $150.00 on 07/05/10, and the check had been deposited to the resident's account on 09/14/10. The facility failed to assure this allegation of misappropriation of resident property was immediately reported and thoroughly investigated as required. -- b) Resident #105 During an interview on 10/27/10 at 3:45 p.m., a family member stated that, while his mother was a resident at the facility, he had visited and found her soaked with urine. He stated he reported this to the administrator. An interview with the administrator, on 11/17/10 at 4:00 p.m., confirmed Resident #105's family member had complained to her of finding his mother wet. The administrator could provide no evidence that this allegation of neglect had been reported and a thorough investigation conducted. -- c) Resident #44 Review of facility documents found Resident #44 reported that, on 09/02/10, she had asked a nursing assistant to put her in bed, and the nursing assistant pushed her down in the bed by her shoulder. Further review found no evidence that any investigation into the validity of this resident's allegation had been conducted by the facility. The facility could provide no evidence that a statement had been obtained from the alleged perpetrator, the resident, or other staff members working at the time the alleged incident occurred. Additionally, it was determined that the required five-day follow-up report had not been faxed until 09/11/10. .",2014-03-01
11461,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,240,G,,,FROJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her ""they had thrown her out and made her go"". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), ""If there was any way possible, I would like her to go, but she probably won't."" He stated his mother had regularly refused to attend appointments outside the facility and he had always been notified by nursing staff she was refusing to go. He stated that neither he nor any staff at the facility had forced his mother to attend an appointment against her wished until this incident. He stated that, if the nurse had contacted him, he would have had them cancel the appointment. He stated his mother still refers to the incident and continues to be upset. Review of Resident #49's medical record found [DIAGNOSES REDACTED]. The resident was receiving seven (7) medications for treatment of [REDACTED]. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/14/10, found the resident was assessed as having no hearing difficulty, demonstrating clear speech and understanding of others, and displaying the ability to make herself understood. Her cognitive skills were assessed as modified independence - with some difficulty in new situations only. Review of the nursing notes found the resident was afforded the right to refuse physician appointments on 05/03/10, 05/12/10, 06/04/10, 07/20/10, 07/29/10, 08/19/10, and 09/28/10. An interview with a member of the ambulance crew (AC) who took the resident to the 11/02/10 appointment (AC #1) was conducted at 12:20 p.m. on 11/17/10. He relayed that Resident #49 was alert and oriented and able to answer questions appropriately. He stated the resident repeatedly verbalized that she did not want to go. He stated she was very upset when they arrived at the appointment and accused them of throwing her on a cot and kidnapping her. He stated that neither he nor the second AC personnel wanted to take the resident after she had refused, but the nurse insisted that they take her. He stated the nurse told them that the POA wanted her to go so they had to take her. An interview with AC #2 was conducted via telephone at 3:30 p.m. on 11/18/10. He stated that, when he arrived with AC #1, the resident was using the porta potty. He stated the resident said four (4) or five (5) times that she did not want to go. He stated the resident was alert and oriented and answered questions appropriately. He stated the nurse insisted that the resident had to go, that her son was POA and wanted her to go, and that they had to take her. He stated that, when they arrived at the appointment, the resident could hardly breath and told her daughter that she had been kicked out of the nursing home. An interview with Employee #98 was conducted at 2:40 p.m. on 11/18/10. She confirmed she was the nurse who sent the resident out for the appointment on 11/02/10. She confirmed that Resident #49 had refused to go when the ambulance crew came to pick her up. She agreed she told the ambulance crew that the family wanted her to go and they had to take her. She stated that the resident had been yelling out constantly for help and calling the family in the middle of the night. She stated the son was in wanting a ""psych"" evaluation to get medicine to make her sleep. When inquiry was made concerning a resident's right to refuse treatment, Employee #98 stated that, if they do not have capacity and the family wants them to go to an appointment, ""then I make them go unless the family calls and tells me that the resident does not have to go."" She stated that, since the family did not call, she forced the resident to go. When asked if she made any attempts to call the family to inform them that the resident had refused to go to the appointment, she stated that she did not try to call them. An interview was conducted with the administrator and director of nursing at 4:45 p.m. on 11/18/10. Both stated that a resident cannot be forced to go to an appointment if they refuse. The DON stated the family should be notified and the appointment rescheduled. .",2014-03-01
11462,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,246,E,,,FROJ11,". Based on resident interview and review of facility records,the facility failed to assure nine (9) of nine (9) sampled residents received prompt assistance when their call bells were activated. Resident identifiers: #95, #78. #58, #67, #6, #25, #49, #44, and #105. Facility census: 104. Findings include: a) Resident #95 In an interview conducted on 11/17/10 at 9:15 a.m., Resident #98 stated that she has great difficulty, at times, getting staff to answer her call light. She stated she has had to wait on occasion from thirty (30) minutes to one (1) hour for assistance. Following the resident interview, a licensed practical nurse (LPN - Employee #99) was noted to be outside the resident's room with a medication cart. When asked how she supervised the unlicensed staff to assure that resident call lights were answered in a timely manner, Employee #99 stated that staff members carry beepers to let them know when a resident's light has gone off. When asked to inspect her beeper, the nurse stated that she had let the nursing assistant (NA) use it. On 11/18/10 at 2:05 p.m., the administrator provided a document which identified how the beeper system operates. Review of the document found that, when a resident activates a call light, the beeper of the NA assigned to the resident goes off. If the call light is not answered after 2.8 minutes, the beepers of NAs on the second wing sound. If the call light is not answered after 8.4 minutes, the nurse's beeper sounds. If the call light is not answered after 11.2 minutes, the beeper of the clinical care supervisor (CCS) sounds. If the call light is not answered within 14 minutes, the beeper of the director of nursing (DON) sounds. The administrator was asked to provide documentation of the wait times for assistance after the call light was activated by Resident #95 for 10/19/10, 10/30/10, and 11/06/10. Review of the information provided found Resident #95's call light was not answered in a timely manner, with the following intervals found between the time the resident activated her call light and the time it was answered by staff: 10/19/10 at 10:54 a.m. - 20.6 minutes 10/30/10 at 6:24 p.m. - 33.9 minutes 10/30/10 at 7:13 p.m. - 26.0 minutes 11/06/10 at 9:27 a.m. - 25.6 minutes 11/06/10 at 12:12 p.m. - 54.4 minutes 11/06/10 at 1:25 p.m. - 80.6 minutes 11/06/10 at 7:09 p.m. - 25.0 minutes -- b) Resident #78 Review of the wait times for assistance after activating the call bell found the resident's call bell was activated for 123.2 minutes on 11/06/10 at 8:06 p.m., before staff responded. -- c) Resident #58 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 10:23 a.m. - 111.6 minutes 11/06/10 at 7:07 a.m. - 82.1 minutes 11/06/10 at 9:33 p.m. - 35.5 minutes 11/06/10 at 8:38 p.m. - 31.0 minutes 11/06/10 at 5:14 a.m. - 35.4 minutes -- d) Resident #67 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 11:37 a.m. - 57.5 minutes 10/30/10 at 10:26 p.m. - 23.4 minutes -- e) Resident #6 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 9:10 p.m. - 38.1 minutes 10/30/10 at 8:44 a.m. - 33.6 minutes -- f) Resident #25 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 10/30/10 at 12:03 p.m. - 39.4 minutes 10/30/10 at 12:57 p.m. - 35.6 minutes 11/06/10 at 1:27 p.m. - 21.5 minutes -- g) Resident #49 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 3:30 a.m. - 27.2 minutes 11/06/10 at 7:26 a.m. - 23.0 minutes 10/30/10 at 5:52 p.m. - 20.5 minutes -- h) Resident #105 Review of the call bell activation document provided by the administrator found the resident waited 41.0 minutes on 10/11/10 at 2:16 p.m. after the call bell was activated. -- i) Resident #44 Review of the call bell activation document provided by the administrator found the resident waited 16.5 minutes on 10/19/10 at 6:17 p.m. after the call bell was activated.",2014-03-01
11332,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,152,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. .",2014-04-01
11333,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,225,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to report allegations involving mistreatment and/or neglect to the appropriate agencies in accordance with State law for three (3) of six (6) sampled residents. Resident identifiers: #37, #38, and #67. Facility census: 89. Findings include: a) Resident #37 A review of the medical record revealed Resident #37 was an [AGE] year old male who has been determined to lack the capacity to form healthcare decisions, and his minimum data set and care plan indicated he was totally dependent upon staff for hygiene. A review of a grievance form revealed that, on 11/16/10, the resident's wife / healthcare surrogate (HCS) reported to a nurse (Employee #7) that the resident's nails were dirty at times and that she always had to cut his nails herself. The nurses' notes indicated this allegation of neglect was investigated and being followed up by Employee #7 and a nursing assistant and, when checked on 11/17/10, his nails were clean. Daily monitoring of the resident's nails was ordered by the physician and added to the care plan. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- b) Resident #38 A review of the clinical record for Resident #38 revealed an [AGE] year old male with [DIAGNOSES REDACTED]. He had been determined by the attending physician to lack the capacity to form healthcare decisions, and his niece was his medical power of attorney representative (MPOA). A grievance form was filed on 11/08/10, after the facility received a letter from the MPOA stating she had spoken to a staff member two (2) weeks prior and complained that the resident had become unable to physically lift his arm enough to feed himself, but nothing had been done and he was still having his tray set up and being left to feed himself. During an interview with the MPOA at 12:50 p.m. on 12/28/10, she verified she had told three (3) different employees about the fact that the resident could no longer feed himself or get a drink of water on his own. The MPOA stated the resident's mouth was very dry and the nurse had told her that he was losing weight. Her only answer from nursing was, ""We'll write it in the notes."" She stated she had asked an aide to feed him but was told they needed to get an ""okay"" from the nurse. She stated that, after she wrote the letter, the facility took action, had tests done, and instructed the staff to feed him. The original assessment by the registered dietitian (RD), on 06/20/10, noted his weight as 204.2 pounds and his intake at 92%. A dietary entry on 12/16/10 noted, ""MPOA aware of Monthly weight trigger; Resident has had a 9.54% wt. loss x 1 month, 10.15% wt. loss x 3 months and 14.68% wt. loss x 6 months."" An investigation took place as evidenced by an immediate speech therapy evaluation; a referral to the Veteran's Hospital for an evaluation of his decline; and, on 11/10/10, he was changed to having meals in the restorative dining room. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- c) Resident #67 A review of the grievance reports revealed that, on 11/15/10, Resident #67 (who had been determined by the attending physician to have the capacity to form her own healthcare decisions on 10/10/10) reported allegations that she was not getting the care she needed. She stated to Employee #8 (the admissions person) that: (1) she could not reach her call bell; (2) she hadn't been gotten out of bed for two (2) days, and (3) one (1) of the aides (Employee #9) had been rude to her when she asked to get up and told her she would have to wait and that he didn't have to do what she said. Employee #8 recorded the allegations and began an investigation, and counseling was done with the staff, but these allegations of neglect were not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. During the investigation, Employee #10 gave a signed statement the resident had also reported to her on 11/12/10, that her light was not being answered. -- d) During an interview with the administrator, the acting director of nursing, and the social worker at 1:45 p.m. on 12/28/10, this surveyor stated to them that the above grievances contained allegations of mistreatment and/or neglect and, as such, should have been immediately reported to the appropriate State officials prior to the initiating of investigations. The outcome of the investigations should also have been reported. The three (3) of them reviewed the grievances and did not offer any alternative explanations but stated that they would file reports as soon as possible. .",2014-04-01
11334,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,323,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to ensure one (1) of six (6) sampled residents was free from accident hazards over which the facility had control, and the facility failed to provide adequate supervision and/or assistive devices by failing to put preventive interventions into place after an identified accident. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of the medical record revealed Resident #23 was a [AGE] year old female, who was alert and oriented, but whose sister who had been appointed to serve as her health care surrogate (HCS) per the social worker, to assist her with healthcare decisions. A facility investigation report indicated that, on 12/15/10, the resident was found with her right foot caught in the siderail of her bed in her bedroom resulting in redness of the entrapped area. The resident had a physician's orders [REDACTED]. A Side Rail Evaluation Screen was completed on 12/27/10, and the decision was made to add padded coverings to the siderails. The assessment nurse (Employee #6) presented a copy of the care plan at 2:00 p.m. on 12/28/10, with an added intervention (hand-written) dated 11/22/10 which read: ""Bilateral 1/2 SR padded for T & R (turning and repositioning)."" An observation of the resident was made at 10:45 a.m. on 12/27/10, while she was lying in bed in her room. Both 1/2 siderails were raised and appeared to have a satisfactory fit to the bed, but there was no padding on the rails. In an interview with the resident at that time, she stated she did like having the rails to use when she moved about in bed. She remembered getting her foot caught in the rail and said she was being careful not to do it again. During a staff interview with the interim director of nurses at 11:15 a.m. on 12/28/10, she acknowledged the padding had not been added until the evening of 12/27/10, when she realized that her instructions to the nursing staff to pad the rails ""on Friday"" had not been carried out. .",2014-04-01
11335,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,514,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by continuing to indicate, in the physician's progress notes, that two (2) of six (6) sampled residents were on medications and/or dosages that had been changed and/or discontinued. Resident identifiers:#37 and #87. Facility census: 89. Findings include: a) Resident #37 A review of the medical record found Resident #37 presently had physician's orders [REDACTED].@ bedtime"" (with a start date of 09/13/10) and ""[MEDICATION NAME] (insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - once daily Everyday: 4 units"" (with a start date of 07/07/10). A review of the physician's progress notes revealed the physician's assistant (Employee #4) had documented on all entries back to 06/15/10 that the resident was receiving the following drug therapy for treatment of [REDACTED]. DM II (diabetes mellitus type II): [MEDICATION NAME] 20U qhs (each night). Presently taking [MEDICATION NAME] 2U with supper and continue 4U with breakfast and lunch. Will continue to monitor qid (four-times-a-day)."" During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented ""the nurses know not to go by (his) notes."" The medical director, who was present at exit, stated that corrections would be made. -- b) Resident #87 A review of the physician's progress notes written by the physician's assistant (Employee #4), on 12/09/10, 10/19/10, 09/21/10, and 08/24/10, all stated Resident #87 was being treated with the following: ""1. [MEDICAL CONDITION]'s chorea: Klonopin 1 mg bid (twice daily). [MEDICATION NAME] mg qhs for [MEDICAL CONDITION]. [MEDICATION NAME] 7.5 mg 1 po (by mouth) qhs."" A review of the record found the [MEDICATION NAME] was discontinued on 07/22/10 and [MEDICATION NAME] discontinued in August 2009. During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented ""the nurses know not to go by (his) notes."" The medical director, who was present at exit, stated that corrections would be made.",2014-04-01
11336,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-01-11,318,E,,,CVPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase strength and/or range of motion (ROM). Thirty-six (36) residents had physician orders [REDACTED]. Resident identifiers: #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Facility census: 76. Findings include: a) Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77 On 01/10/11, a review of the facility's ""Restorative Nursing and Progress Summary"" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, twenty-four (24) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on five (5) of ten (10) days. These were Residents #2, #5, #7, #8, #10, #12, #15, #24, #25, #33, #35, #42, #43, #44, #50, #57, #60, #61, #63, #64, #67, #68, #73, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on anywhere between three (3) and eight (8) days of this month. These were Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Each resident had one (1) or more physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She stated, ""I am a van driver."" An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's ""Restorative Nursing and Progress Summary"" marked with an ""X"" indicated that the restorative services was not provided for the resident. She reported the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor.",2014-04-01
11337,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-01-11,311,E,,,CVPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase self-performance of transfer / ambulation and/or eating activities. Twenty-four (24) residents had physician orders [REDACTED]. Resident identifiers: #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Facility census: 76. Findings include: a) Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77 On 01/10/11, a review of the facility's ""Restorative Nursing and Progress Summary"" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, fourteen (14) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on five (5) of ten (10) days. These were Residents #2, #5, #7, #12, #15, #24, #33, #41, #52, #57, #61, #68, #74, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on anywhere between three (3) and eight (8) days of this month. These were Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Each resident had a physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She further stated, ""I am a van driver."" An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's ""Restorative Nursing and Progress Summary"" marked with an ""X"" indicated that the restorative services was not provided for the resident. She further stated that the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor. .",2014-04-01
11338,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-12-09,225,D,,,9K0R11,". Based on review of abuse / neglect policies, review of employees' personnel files, and staff interview, the facility failed make reasonable efforts to uncover information about any past criminal prosecutions to assure that individuals are not employed who have been potentially found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of seven (7) employee personnel records reviewed. Facility census: 115. Findings include: a) The facility was entered at 12:15 p.m. on 12/09/10, to conduct an unannounced complaint investigation alleging that the facility did not perform necessary screening for potential employees to rule out criminal convictions that would make them unfit for service in a nursing facility. Review of the facility's policy addressing the prevention of resident abuse / neglect ""1.0-WV Abuse Prohibition"" (revised 11/01/09) found the following under the section entitled ""Process"": ""2. The Center will screen potential employees for a history of abuse, neglect, or mistreating residents... ""2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service..."". Review of the personnel file for nursing assistant (NA) #1 found she had previously worked in the Commonwealth of Virginia. The personnel file contained no evidence to reflect the facility made a reasonable effort to determine whether this individual had criminal convictions in Virginia which would render him / her unfit to work in a long term care facility. An interview with the administrator, on 12/09/10 at 3:10 p.m., confirmed the facility had no evidence that NA #1 had been screened for criminal convictions in Virginia.",2014-04-01
11339,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,157,D,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. Record review of nursing notes, from [DATE] until her death on [DATE], found no evidence of communication to the family related to Resident #111 participating in the fine dining or walk-to-dine program. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. .",2014-04-01
11340,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,280,D,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. There was also no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 4. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 5. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. .",2014-04-01
11341,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,323,G,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON agreed that Resident #111 was not using a tab alarm, self-releasing seat belt, or wheelchair at the time of the fall in the dining room on [DATE]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. -- 8. During an interview with a member of the activities staff (Employee #35) on [DATE] at 3:20 p.m., she said she was the only staff member in the dining room on [DATE] at the time Resident #111 fell , although she was not assigned to be in the dining room that day at any certain time. She said she went to the kitchen on her own initiative on [DATE], to check if any of the trays were ready or if the dietary staff needed her to start pouring drinks. When asked, she said the noon meal was typically served at 12:10 p.m. in the dining room. She stated that, at 11:45 a.m. on [DATE], she looked up and saw Resident #111 walking and hurried to her, but she could not reach the resident before she fell . She said the resident had no alarm or safety belt in place and she was sitting at the table by herself. -- 9. When asked, during an interview on [DATE] at 4:00 p.m., why Resident #111 was in the dining room so early before the meal, the DON said Resident #111 was one of the easiest residents to walk, so she would have been one of the first brought down to the dining room. She said there was no written safety policy or procedure regarding the use of alarms or seat belts that she could find related to fine dining. Resident #111 had an order for [REDACTED]. .",2014-04-01
11342,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,155,D,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" -- 3. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for 12/03/10, ""7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 4. The ER record dated 12/03/10 stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- 5. A physician's progress note, dated 12/05/10, stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on 12/03/10, all further treatment was done by him. -- 6. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. .",2014-04-01
11343,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,157,D,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure, for one (1) of seven (7) sampled residents, the physician was notified of an acute change of condition (the presence of a large hematoma), and failed to consult the physician and notify an interested family member prior to a significant alteration in treatment. Resident #118 (who had multiple comorbidities and was on anticoagulation therapy) developed a large hematoma on her left lower extremity, and the facility failed to notify the attending physician of the hematoma. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage) on the hematoma without consulting with the attending physician and without informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. The physician and the MPOA were contacted after the procedure resulted in significant bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on 12/02/10, Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for 12/03/10, ""7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 6. The ER record dated 12/03/10 stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- A physician's progress note, dated 12/05/10, stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" -- 8. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. The termination of the services of the CNP was confirmed by the administrator during the exit conference. .",2014-04-01
11344,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,224,G,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. The resident's cardiovascular disease was being treated with long-term [MEDICATION NAME] therapy, which included regular monitoring of her [MEDICATION NAME] time (PT) and INR. PT evaluates the ability of blood to clot properly; INR (International normalized ratio) is a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Hemostasis for reporting the results of blood coagulation (clotting) tests. The lab's normal ranges for these tests were PT - 9.2 to 11.8 and INR - 2.0 to 3.0. Record review revealed the following lab results and adjustments made to her [MEDICATION NAME] order in November and [DATE]: Date - [MEDICATION NAME] Dosage - PT / INR - New Order [DATE] - 2.5 mg daily - 42.1 / 4.3 - hold x 2 days [DATE] - ([MEDICATION NAME] held) - 39.8 / 4.1 - [MEDICATION NAME] 2.0 mg daily [DATE] - 2.0 mg daily - 34.5 / 3.4 - [MEDICATION NAME] 1.5 mg daily [DATE] - 1.5 mg daily - 25.8 / 2.4 - same [DATE] - 1.5 mg daily - 27.3 / 2.5 - same [DATE] (at 12:00 p.m.) - 1.5 mg daily - 23.0 / 2.0 - same [DATE] (at 8:10 p.m.) - 1.5 mg daily - 23.3 / 2.3 - same On [DATE], the physician gave orders to discontinue the [MEDICATION NAME] and obtain a repeat PT/INR. -- 3. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 4. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" - There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 5. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for [DATE], ""7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 6. The ER record dated [DATE] stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 7. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, ""Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings."" At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that ""... area to left leg slightly red warm and hard around wound"", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was ""Acute [MEDICAL CONDITION]"". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) ""is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..."" (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an ""unusual occurrence"". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation. The termination of the services of the CNP was confirmed by the administrator during the exit conference. .",2014-04-01
11345,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,225,D,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to immediately report to State agencies and/or thoroughly investigate an incident involving the neglect of one (1) of seven (7) sampled residents. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. This event was reported to the State survey and certification agency as an ""unusual occurrence"" without evidence of a thorough investigation. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for [DATE], ""7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 5. The ER record dated [DATE] stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 6. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, ""Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings."" At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that ""... area to left leg slightly red warm and hard around wound"", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was ""Acute [MEDICAL CONDITION]"". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) ""is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..."" (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an ""unusual occurrence"". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation.",2014-04-01
11346,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,157,D,,,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide prompt notification, to the responsible party of one (1) of forty-two (42) Stage II sample residents, after the resident experienced a change in condition. Resident #120 became agitated while in the dining room on 11/12/10, and the nurse aides had to carry the resident back to her room due to her increased agitation, resistance of care, and physically aggressive behaviors. The resident's medical power of attorney representative (MPOA) did not learn of these events until 11/16/10. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 On the night of 11/12/10, Resident #120 exhibited agitated behaviors that were atypical for her. According to documentation recorded by a licensed practical nurse (LPN - Employee #114), the resident was in the dining room by herself when she became agitated and started carrying around a wet floor sign, hitting the window of the dining room with the wet floor sign. The resident was soiled also due to incontinence. When nurse aides approached her and tried to get her to her room (in order to provide incontinence care), she became more agitated, hitting and kicking the nurse aides. Nurse aides eventually had to carry the resident from the dining room to her room, in order to change her out of her soiled clothes. On 01/06/11 at approximately 2:00 p.m., the social worker (Employee #134) provided a copy of documentation she had collected on 11/16/10. The documentation stated, ""(Name), daughter and MPOA for (Resident #120), came into the office about 1:25 PM this date and stated that (name of Employee #73), CNA (certified nursing assistant), told her there was a rumor that 3 CNA's (sic) on south side turned in 3 CNAs from north side for abuse of (Resident #120). The story is that Friday, 11/12/10, night (Resident #120) was hitting and combative with staff. In an attempt to get her calmed they restrained her and in the process bruised her pretty bad. (Daughter's name) indicated that she (the resident) has bruising on her left wrist, right wrist, and a dark blue spot further up her right arm. (Employee #73) told (daughter's name) names (sic) of two CNAs, (names of Employees #65 and #54) both of whom work 3-11 shift. (Daughter's name) was also told that one of the CNAs was new. She inquired about the process when something like this happens. It was explained generally about investigating and reporting. She was rather upset understanding (sic) however, her mother's behaviors at times (sic) but was concerned about the bruises. She was assured we would keep her informed. ..."" The resident's daughter became aware of the above incident on 11/16/10, when she came to the facility and Employee #73 approached her with the above information. According to the administrator, the information given to the daughter by Employee #73 did not portray what actually occurred. According to the administrator, Employee #73 did not work on the night of 11/12/10 and had no direct knowledge of what happened, and Employee #73 received a disciplinary action for her actions. On 01/06/11 at approximately 4:00 p.m., the director of nursing (DON) confirmed the facility did not contact the resident's daughter to inform her of what had occurred on 11/12/10. She stated Employee #114 used her nursing judgement on 11/12/10 and elected to not contact the resident's MPOA to inform her of her mother's behavior and of the actions taken to get the resident back to her room and in a more calm state. The DON and the administrator both confirmed the events on 11/12/10 were not typical for the resident. They attributed the increase in aggression to the resident's [DIAGNOSES REDACTED]. .",2014-04-01
11347,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,309,D,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, staff interview, and resident interview, the facility failed to provide necessary care and services for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was receiving blood thinners and was observed with excessive bruising to bilateral upper extremities. There was no documentation that the use of blood thinners was being monitored for this resident. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of recent laboratory results, dated 09/09/10 and 11/08/10, found no laboratory results used for monitoring the effectiveness of the blood thinner to regulate clotting. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 4:00 p.m., Resident #15 reported, ""I can barely just touch or scratch myself and I bruise. I am on blood thinners, and I think it needs to be checked. I was going to talk to my doctor about it, but I haven't seen him."" In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, ""We know we have a problem with documentation, and we are working on it."" Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. Interview with the licensed practical nurse (LPN) assigned to Resident #15 (Employee #159), on 12/22/10 at 5:20 p.m., revealed he was not aware of any bruising to Resident #15's bilateral upper extremities. .",2014-04-01
11348,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,514,D,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed to maintain a complete clinical record for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was observed with excessive bruising to bilateral upper extremities, and there was no documentation that two (2) of three (3) weekly body audits had been completed in the month of December 2010. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, ""We know we have a problem with documentation, and we are working on it."" Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. (See also citation at F309.)",2014-04-01
11349,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,323,G,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and chronic obstructive pulmonary disease. The assessor did not identify, as active diagnoses, either osteoporosis or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): ""ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia."" Goals associated with this problem statement were: ""Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning."" Interventions to meet these goals included: ""Tranfer (sic) with 2 person / Mechanical Lift (sic)."" (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - ""Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') edema, (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station."" The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it ""error"", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - ""C/O (complaint of) pain in left leg. PRN (as needed) analgesic x 1 per order /c (with) No (sic) relief."" - 09/03/10 at 2:30 a.m. - ""Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..."" - 09/03/10 at 3:15 a.m. - ""Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)."" - After the resident's transfer to the hospital on [DATE], Employee #134 recorded the following series of late entries: - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 7:30 p.m. Resident complaint (sic) of pain to left leg. Assessment completed to left leg. (Symbol for 'no') bruising noted. (Symbol for 'no') redness. (Symbol for 'no') edema, or scratches noted to left leg. resident (sic) c/o pain in the knee area. Resident stated 'I can't feel my legs.' Call placed to MD. resident (sic) medicated for pain per order. Will continue to monitor."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 8:00 p.m. MD return (sic) call obtain (sic) order for stat xray (sic). POA (power of attorney) aware. (Name of mobile imaging company) aware."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 8:45 p.m. Xray's (sic) obtained, daughter /c resident at bedside. (Symbol for 'no') complaints of pain at this time. Will continue to monitor resident and await the report."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 10:20 p.m. Resident resting in bed. (Symbol for 'no') discomfort noted. (Symbol for 'no') complaints of pain noted. Awaiting xray (sic) to be faxed to nurses (sic) station. (Symbol for 'no') edema, (symbol for 'no') bruising, (symbol for 'no') redness noted to left leg. Will continue to monitor."" This was the last entry in the resident's nursing notes; she did not return to this facility after being transferred to the hospital on [DATE]. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a ""date of exam"" of ""2010-09-02"" (09/02/10) contained the following impression: ""Left tibia-fibula - Mildly displaced acute fracture of the proximal fibular shaft and fibular head demonstrated."" There was no evidence to reflect this acute displaced fracture of the left fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of osteoporosis or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: ""Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..."" The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be ""Unknown"". - Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) transferred the resident on 09/02/10 without using a mechanical lift as identified in the resident's comprehensive assessment and care plan. - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: ""During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: ""'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' ""'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. ""We didn't use a gait belt; we didn't use a mechanical lift. ""'I did not check the Patient information worksheet.' ""'I know we are a no lift company.' ""'I have used the lift in the past.' ..."" -- 5. Upon request, the facility provided a copy of the policy titled ""Mechanical Lift"" (dated 03/10/10). According to this document, the purpose of the policy is ""(t)o move immobile or obese patients for whom manual transfer poses potential for staff or patient injury"". Review of the facility's employee handbook revealed, under the heading ""Safety Rules"" on page 38: ""1. Report all accidents immediately, no matter how minor, to your supervisor. Your supervisor is required to make a thorough investigation and to complete an Accident Investigation Report. You are required to complete an Employee Incident Report for on-the-job accidents. ""2. Utilize appropriate lifting techniques and body mechanics for all lifting, including patient / resident transfers. All lifting must be performed in accordance with location procedures. Utilize mechanical lifting equipment where appropriate. ..."" -- 6. On the Patient Information Worksheet, Resident #147 was listed as requiring ""2 person / Mechanical Lift"". -- 7. In an interview on 12/22/10 at approximately 3:00 p.m., Employee #134 stated she did work on 09/02/10. She came back to work on 09/09/10 and recorded additional documentation in Resident #147's medical record, after she realized she had made an error regarding the time of the incident in her original note. Employee #134 stated a nurse aide did inform her that the resident complained of pain on the evening of 09/02/10. She assessed the resident's leg, and the resident did not appear to have any swelling, redness or tenderness to her leg during the assessment. She assisted the mobile imaging company during their x-ray of the resident's leg, and the resident did not appear to be in any pain at that time. -- 8. In an interview on 12/22/10 at approximately 3:30 p.m., Employee #141 stated his employment was terminated after this incident, but he was later asked to return to work. He reported he was not the aide assigned to Resident #146 on 09/02/10, but he did assist his co-worker (Employee #152) on that day. He verified they did not use a mechanical lift to transfer the resident from her wheelchair to her bed. He agreed he should have looked to see what type of assistance the resident needed for transferring before he assisted Employee #152, but he reiterated that he had his own assignments and had just agreed to help out a co-worker with a transfer on 09/02/10. -- 9. The assistant director of nursing (ADON - Employee #139) confirmed, during an interview on the afternoon of 12/22/10, the facility was a ""no lift company"". The ADON also confirmed that no incident / accident report was completed related to the events that took place on the evening of 09/02/10 involving Resident #147. -- 10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. .",2014-04-01
11350,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2010-12-16,225,D,,,17LC11,". Based on record review, staff interview, and confidential staff interview, the facility failed to report an allegation of resident neglect by a nursing assistant to the appropriate State officials agencies when the identity of the alleged perpetrator was known. This was evident for one (1) of five (5) sampled residents. Resident identifier: #32. Facility census: 65. Findings include: a) Resident #32 Record review revealed Resident #32 received a head injury of unknown origin. Subsequently, this resident was transported to the emergency room for evaluation, then returned to the facility the same day. Record review revealed the facility reported this injury of unknown source to the appropriate State agencies, because the source of the injury was not observed by any person, it could not be explained by the resident (who was cognitively impaired due to a disease process), and the injury was suspicious because of the location and extent of the injury. Further record review revealed a licensed practical nurse (LPN - Employee #32) completed an incident report on the date and time of the discovery of the injury and documented an allegation that a nursing assistant caused the injury during turning and failed to notify the nurse of what she had done. -- Interview with the administrator, director of nursing, and the licensed social worker, on 12/14/10 at 3:00 p.m., revealed their belief that it would have been physically impossible for Resident #32's head to hit the bedside stand while being turned; they reported the aides ""speculated"" about what might have happened, and a former employee (Employee #84, a nursing assistant who was terminated last week) and other staff who were working the evening of the incident, when interviewed, admitted having no knowledge of how the injury happened. Subsequently, the administrator felt the allegation was hearsay, and the facility did not substantiate abuse or neglect in their investigation of the incident. -- Interview with Employee #32, on 12/14/10 at 3:25 p.m., revealed that the identity of Employee #84, who allegedly caused a head injury to Resident #32, was told to her and she included this allegation on the incident report but without writing the names of the alleged perpetrator or the reporter of this information. -- In an interview, another LPN (Employee #58) confirmed that she, too, was told of the allegation at the same time as Employee #32, that Employee #84 had allegedly caused the head injury while turning the resident but did not tell the nurse what she did. -- A confidential interview with member of the facility's nursing staff, on 12/15/10 at 12:25 p.m., revealed she heard Employee #84 admit to having injured Resident #32 while turning the resident alone, striking the resident's head against the overbed table, but was afraid to tell the nurse. -- During an interview with the administrator on 12/14/10 at 5:00 p.m., she acknowledged the allegation made against Employee #84 should have been reported to the Nurse Aide Abuse Registry, even though the facility did not substantiate abuse or neglect in their internal investigation. .",2014-04-01
11351,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2010-12-16,281,D,,,17LC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders to perform monthly laboratory testing for one (1) of five (5) sampled residents. One (1) resident in the sample did not receive a monthly complete blood count (CBC) per physician's orders, as evidenced by one (1) CBC lab test omission in March 2010. A CBC drawn a month after the omitted lab test, in April 2010, revealed abnormal findings resulting in the resident's hospitalization Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Record review revealed Resident #67 was diagnosed with [REDACTED]. A hospice encounter occurred in September 2009 but was declined by the family. Review of a facility's Encounter Sheet, dated 12/10/09, revealed the physician was to be consulted regarding increasing the [MEDICATION NAME] dosage, as this resident with multiple contractures and ""pain expressed (symbol for with) even slightest movement"". -- Record review revealed Resident #67's physician orders included orders for a basic metabolic profile (BMP) every three (3) months and CBC every month. Review of physicians orders effective from 03/01/10 through 03/31/10 revealed both the BMP and the CBC were both due on 03/10/10 and all CBCs were to be sent to Hospital #1. The BMP, requested and completed on 03/19/10 by the contracted lab service at Hospital #2, yielded results similar to the previous quarterly BMPs; however, there was no evidence to reflect the monthly CBC was requested and/or completed in March 2010. A CBC, requested and completed by the contracted lab service at Hospital #2 on 04/23/10, contained the following abnormal laboratory results: - WBC (white blood cell count) 1.2 (normal reference range 4.9 - 10.8); - RBC (red blood cell count) 1.98 (normal reference range 4.20 - 5.4); - HGB (hemoglobin) 5.9 (normal reference range 12.0 - 16.0); - HCT (Hematocrit) 18.3 (normal reference range 36 - 48%); and - PLT (Platelet) 44 (normal reference range 140 - 440). Review of past lab results revealed Resident #67's monthly WBC ranged from 5.8 in October 2009 to 6.4 on 02/22/10. The hemoglobin ranged from 9.2 in October 2009 to 8.6 on 02/22/10. The hematocrit ranged from 29.0 in October 2009 to 27.7 on 02/22/10. The platelets ranged from 188 in October 2009 to 222 on 02/22/10. -- Review of the interdisciplinary progress notes for 04/23/10 at 10:45 p.m. revealed Resident #67 was admitted to the hospital with [REDACTED]. Review of the interdisciplinary progress notes for 04/30/10 at 1:00 p.m. revealed the resident's medical power of attorney representative (MPOA) stated he had found placement for this resident at another facility, which had a private room the resident needed, and she would be transferred there following the hospital discharge. -- Interview with the administrator, on the early afternoon of 12/16/10, revealed a CBC report could not be located from either of the two (2) hospitals for March 2010.",2014-04-01
11352,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,279,D,,,I2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to develop care plans, for one (1) of thirteen (13) sampled residents and one (1) resident of random opportunity, to reflect each resident's needs and the services being furnished to attain or maintain the resident's highest practicable physical well-being. One (1) resident had a physician's orders [REDACTED]. Another resident had sustained an injury when she spilled hot chocolate on herself, and no mention of this was made on the care plan in order to prevent another such incident. Resident identifiers: #8 and #13. Facility census: 54. Findings include: a) Resident #8 During a random tour of the facility on 08/18/09 at 2:00 p.m., observation found Resident #8 in her bed with side rails up on both sides. Review of the resident's medical record disclosed that, although the resident did have a physician's orders [REDACTED]. b) Resident #13 A review of the accident / incident reports and nursing notes found, on 06/08/09, Resident #13 ""fell asleep before breakfast in dining room with hot chocolate in her hand and spilled hot chocolate in her lap."" The resident's upper and inner thighs were red, with [MEDICATION NAME][MEDICAL CONDITION] the resident's upper inner bilateral thighs. When interviewed on 08/19/09 at 10:00 a.m., the resident related she was not sure whether she fell asleep or her fingers / hands were not good at holding things as well as before, and she was not sure exactly how the incident happened. She did not think the staff was doing anything differently since the incident occurred related to how she received hot liquids. A review of the resident's current care plan failed to find anything addressing how to promote resident safety with respect to drinking hot liquids without becoming burned. .",2014-04-01
11353,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,309,E,,,I2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three (3) of thirteen (13) sampled residents and three (3) residents of random opportunity. One (1) resident was hospitalized with a toxic level of medication, and no follow-up labs were completed after the resident's return to the facility. Five (5) residents were observed with side rails up and had no physician's orders for the use of side rails and no mention of their use in the plan of care. Resident identifiers: #40, #43, #15, #52, #30, and #41. Facility census: 54. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 08/17/09, disclosed the resident was admitted to the facility on [DATE] from Health South following a [MEDICAL CONDITION] hip. At the time of admission, the resident was receiving the medication [MEDICATION NAME] 0.25 mg every day for the [DIAGNOSES REDACTED]. On 07/12/09, the resident was noted in nursing notes to be nauseous and having an episode of vomiting. The resident's son insisted she be transferred to the emergency room , from which she was admitted to the hospital with [REDACTED]. The resident returned to the facility on a decreased dose of [MEDICATION NAME] (0.0625 mg) and a potassium supplement on 07/20/09. A document entitled ""Physician's Orders"", received from the hospital, displayed an order which stated: ""Dig ([MEDICATION NAME]) level next week at The Madison."" The hospital discharge summary referenced above stated, ""Check her [MEDICATION NAME] level within one week and then do it every month thereafter until she is stable and then she can do it once or twice per year."" Further review of the record, on 08/17/09, divulged no evidence that a [MEDICATION NAME] level had been obtained since the resident's return to the facility. The facility's director of nurses (DON), when interviewed on 08/18/09 related to this finding, stated the resident's attending physician had not ordered a [MEDICATION NAME] level when the resident returned or at any time since she returned. The DON further stated it was not facility practice to carry out orders from a physician who had cared for the resident during hospitalization unless the attending physician concurred. A confidential interview with two (2) facility nurses related to this finding, on the afternoon of 08/18/09, disclosed that both nurses were not comfortable with no recheck of the resident's [MEDICATION NAME] level, and both felt the attending physician should have been questioned specifically about an order for [REDACTED]. The resident's physician was contacted on the afternoon of 08/18/09, and an order was received to obtain a [MEDICATION NAME] level for this resident. b) Resident #43 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #43 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. c) Resident #15 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #15 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. d) Resident #52 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #52 in bed with side rails up on both sides of the bed. The medical record of this resident disclosed that, although the resident had a pre-written document on his record with ""Side rails up when in bed"" checked, the document was signed only by a facility nurse; the resident's physician had not signed the order. When reviewed, no mention of the use of side rails was made in the plan of care for this resident. e) When interviewed on 08/18/09 at 2:45 p.m., the assistant director of nurses stated all residents who were using side rails in the up position should have a current physician's order. f) Resident #30 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a low position, and there were safety mats on the floor. Review of the August 2009 physician's orders found the resident was to use half side rails for ""turning and positioning"". A review of the side rail assessment, dated 04/11/08 and revised on 11/04/08, 12/11/08, 02/10/09, 03/10/09, 04/08/09, 05/01/09, 06/06/09, 07/12/09, and 08/12/09, found each time the assessment was updated, there were no changes with a only comment indicating the resident used half rails as an enabler. There were no comments on the side rail assessment as to how the assessment was completed or whether the resident was observed in order to complete the assessment. Documentation on the front of the assessment stated, ""The resident had intermittent confusion, was able to get out of bed safely with assistance, had a history of [REDACTED]."" A fall risk assessment, dated 07/26/09, indicated the resident was rated a ""10"" or at high risk for falls. The mini mental status exam, dated 11/02/08, indicated the resident had severe dementia. The minimum data set assessment, dated 08/06/09, indicated the resident has fallen within the last thirty (30) days, used the side rails for bed mobility / transfer, required extensive assistance of one (1) for bed mobility, and was totally dependent on one (1) person for transfer. The most recent care plan, dated 05/30/09, indicated the resident was at risk ""for falls related to history of falls, lack of safety awareness related to dementia"", but it did not address the use of side rails in the care plan. A confidential staff interview, on the afternoon of 08/18/09, found the resident was unable to use the side rails and often resisted care by staff. When questioned regarding the resident's ability to hold onto the side rails during care, the staff member indicated the resident only did this occasionally. During an interview with the director of nursing on 08/19/09 at 2:30 p.m., she indicated the resident's ability to use the side rails varied. g) Resident #41 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a medium height position. A side rail assessment, completed on 05/11/09 and revised on 06/07/09, 07/12/09, and 08/12/09, reflected the resident did not use side rails. The 06/12/09 minimum data set assessment indicated the resident used side rails for mobility / transfer, with the self-performance of bed mobility and transfers requiring the extensive assistance of one (1) staff member, and a fall having occurred during the previous thirty (30) days. Review of the physician's orders for August 2009 failed to find physician's orders for the side rails. The current care plan, dated 06/30/09, did not address the use of side rails for the resident. During an interview with the administrator and the DON on 08/19/09 at 2:30 p.m., the DON indicated this resident was not supposed to have side rails in use. .",2014-04-01
11354,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,159,D,,,I2SV11,"Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to individuals who did not have the legal authority to receive this information. This was evident for two (2) of four (4) residents whose personal funds were reviewed. Residents #7 and #57. Facility census: 54. Findings include: a) Residents #7 and #57 A review of the financial information for Residents #7 and #57 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal funds records with the business office manager, on 08/20/09 at 10:00 a.m., found quarterly financial statements were sent to unauthorized representatives for both residents. .",2014-04-01
11355,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,371,F,,,I2SV11,"Based on observation and staff interview, the facility failed to store foods under sanitary conditions. Cold temperatures for milk at 41 degrees F or less were not maintained. Milk from the milk machine temperatures were observed at 42 -50 degrees Fahrenheit (F). This had the potential to affect all residents who drank milk. Facility census: 54. Findings include: a) Observation of preparation of the noon meal, in the dietary department on 08/19/09, found milk in small glasses on a tray in the kitchen. A request was made for one (1) of the cooks (Employee #3) to take the milk temperatures. The first temperature read 50 degrees F, and the second read 45 degrees F. A request was made to take the temperature of milk just after it came from the milk dispenser; this was 45 degrees F, while the external thermometer on the dispenser read 42 degrees F. The temperature of milk dispensed from the machine was measured another thermometer, which read 43 degrees F, while the internal thermometer inside the dispenser read 30 degrees F. Employee #3 and the dietary supervisor were both present. A request was made to review the temperature logs for the milk dispenser. The employee reported she recorded temperatures for both the cooler and the milk dispenser, and it could not be determined whether the temperature logs were for the cooler or the milk dispenser. The temperatures varied from 38 degrees F to 40 degrees F, according to the log, and were listed as measuring the temperature of the refrigerator. .",2014-04-01
11356,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-08-26,323,G,,,3L9811,". Based on observations, the facility failed to ensure the resident environment remained as free of accident hazards as possible. A treatment cart was found unlocked and unattended on the Blue Ridge hall in the presence of mobile residents. The cart contained items that had the potential to be harmful if ingested or used in a manner other than they were intended to be used. All mobile residents on the Blue Ridge hall had the potential to be affected. Facility census: 114. Findings include: a) Treatment cart - unlocked and unattended During random observations of the facility on 08/24/10 at 7:30 a.m., the treatment cart of Blue Ridge was found sitting outside of the Blue Ridge nurses' station. The cart was not locked, and no staff was in line of sight of the cart. The cart contained a variety of treatment supplies, i.e., a container of Greer's Goo (composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste), Nystop (an antifungal), and a large bottle of 100% Acetone. There would be a potential for adverse reactions should a resident who was sensitive / allergic to Mycostatin or Nystop have contact with the Greer's Goo and / or Nystop. Acetone (http://www.drugs.com/enc/acetone-poisoning.html) has the potential to cause cardiovascular problems (hypotension), gastrointestinal problems (nausea, abdominal pain, vomiting), the nervous system may be affected (seem as though drunk, coma), as might the respiratory system .",2014-04-01
11357,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,323,G,,,9G3Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as ""Nose Deformity /c (with) Bruising & Nose bleed"". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading ""Protective Devices"" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., ""Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip."" There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., ""Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)."" Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., ""Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again"", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., ""Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit."" Under the heading ""Description of Injury"" was written ""2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt."" Under the heading ""Protective Devices"" the author noted a reclined geri-chair was in use at the time of the fall due to ""freq. (frequent) falls"". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a ""Right to Fall Policy""; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: ""Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness."" The goal associated with this problem statement was: ""Resident will have < (symbol for 'less than') 2 falls per day x 90 days."" The interventions intended to assist the resident in achieving this goal were: ""Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. "" There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. .",2014-04-01
11358,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,323,G,,,777711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as ""Nose Deformity /c (with) Bruising & Nose bleed"". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading ""Protective Devices"" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., ""Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip."" There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., ""Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)."" Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., ""Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again"", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., ""Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit."" Under the heading ""Description of Injury"" was written ""2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt."" Under the heading ""Protective Devices"" the author noted a reclined geri-chair was in use at the time of the fall due to ""freq. (frequent) falls"". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a ""Right to Fall Policy""; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: ""Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness."" The goal associated with this problem statement was: ""Resident will have < (symbol for 'less than') 2 falls per day x 90 days."" The interventions intended to assist the resident in achieving this goal were: ""Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. "" There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls.",2014-04-01
11359,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,250,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 2:21 p.m., the administrator confirmed there was no evidence the facility's social services had initiated a discharge plan related to Resident #35 being transferred to another facility, although the administrator confirmed the facility had started to work on discharging Resident #35 to a facility in Ohio prior to the resident being sent to the hospital on [DATE]. When the administrator was asked for social service notes, she stated, ""Yes, there should be some kind of discharge information started and written in the chart, but there is not, and I can't say why it's not there."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. b) Resident #31 On 12/02/10 at approximately 3:00 p.m., Resident #31 stated he had a medical appointment scheduled for today, but he did not go to this appointment. He said no one told him about the appointment and therefore he did not know he had to go. He said the ambulance attendants came to his room and he did not know why they were there. They informed him they were taking him to a local hospital for some medical test. He chose not to go with them, because according to him, he ""did not know anything about an appointment until the ambulance people came to (his) room."" The nurse aide (Employee #65) said she came to work at 7:30 a.m. on 12/02/10. She indicated no one had informed her Resident #31 had an appointment on 12/02/10. According to Employee #65, the night shift nurse aide had already made the bed, and the resident had his clothes on for the day. Employee #70 (a registered nurse) said the physician had told Resident #31, on 11/29/10, he had an appointment on 12/02/10. She went on to say things were chaotic on the morning of 12/02/10, and she had forgotten to remind Resident #31 of his appointment today. She agreed the resident the nursing staff should remind residents of their scheduled appointments on the day of the appointment. Resident #31 recently had a computed tomography (CT) scan where lesions and tumors were found on his liver. The appointment on12/02/10 was scheduled for further testing related to these issues. .",2014-04-01
11360,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,201,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 11:51 a.m., the administrator confirmed it was her preference to not permit the resident to return to the facility. She said, ""We told the resident it was not appropriate behavior."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. On 12/09/10, the responsible party for Resident #35 was contacted and said he was told the facility could not take Resident #35 back because of his behaviors. He said he would rather Resident #35 stay at this facility, since the new facility was located 120 miles away. The responsible party stated, ""The facility said they could not take him back."" At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. In addition, the care plan did not address the variety of behaviors and/or have interventions which would lead to problem identification and/or correction. There was no evidence to reflect the facility attempted to meet the resident's needs prior to making the determination that they could no longer care for him. .",2014-04-01
11361,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,279,E,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, ""I really want to get rid of my belly."" Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: ""Resident wants to lose wt (weight)."" Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: ""Resident wants to continue to lose wt per her choice due to history of diabetes."" An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with an RN (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. c) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. d) Resident #115 During an observations of the dinner meal on 11/29/10 at 6:00 p.m., Resident #115 was observed to be eating in the area designated as the restorative dining area. She was falling asleep. After the others were served, the restorative nursing assistant fed the resident her meal. The medical record, when reviewed on 11/30/10, found Resident #115 had been evaluated by the speech-language pathologies (SLP) for dysphagia with recommendations made on 11/12/10. The SLP stated the goal for this resident was ""to decrease risk of aspiration and increase PO (by mouth) intake"". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. The resident's most recent interdisciplinary care plan, dated 11/22/10, was reviewed. This plan did not include a restorative nursing care plan, did not identify this resident was at risk for aspiration, and did not include interventions to prevent aspiration and address the resident's swallowing problems as recommended by the SLP. The restorative nursing assistant (Employee #94) was observed feeding this resident lunch at 12:15 p.m. on 12/02/10. The resident had a straw in her milk and was given four (4) to five (5) bites between drinks, instead of two (2) to three (3) bites as recommended by the SLP. The director of nursing (DON), when interviewed at 3:30 p.m. on 12/03/10, reviewed the resident's care plan and verified there was no restorative care plan. .",2014-04-01
11362,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,319,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. .",2014-04-01
11363,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,364,F,,,GCMN12,". Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were at appropriate temperatures; however, the cold food (coleslaw) was 51.4 degrees Fahrenheit (F). According to State law, cold foods, at the time of receipt, can measure no more than 50 degrees F. Due to the confusion of getting test trays, another test tray was requested. This one was immediately following the last tray served in the dining room. The tray was tested at 1:15 p.m., with the DM. The hot foods were again at appropriate temperatures; however, the coleslaw was 54.7 degrees F. Upon inquiry, the DM stated the coleslaw was prepared that morning. When asked the size and depth of the pan used to chill the coleslaw, the DM showed the surveyor a 6-inch deep 1/2 steam table pan. This pan was not shallow enough to allow for rapid chilling of cold foods. .",2014-04-01
11364,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,246,D,,,MWZ111,"Based on observation, staff interview, and record review, the facility failed to ensure proper positioning of one (1) randomly observed resident in restorative dining. A resident in a scoot chair was observed eating lunch while the back of his scoot chair was in a reclined position. The reclined position of the chair back interfered with the resident's ability to reach his food. Resident identifier: #189. Facility census: 102. Findings include: a) On 06/29/09 at 12:25 p.m., observation found Resident #189 eating in the restorative dining room. The resident was seated in a scoot chair. The scoot chair's seat was low to the ground, and the backrest was observed to be in a reclined position. The table height was too high for the resident to comfortably reach his food. The resident, who was attempting to feed himself, was having difficulty reaching the food on the table and was spilling some food onto his chest. The resident, when observed on 07/02/09 at 12:30 p.m. in the restorative dining room., was again in the scoot chair seated at the table. The backrest to the chair was observed in a reclined position. The resident was observed having difficulty reaching the food on the table. When interviewed on 07/02/09 at 12:45 p.m., the speech language pathologist (SPL - Employee #17) stated the backrest to the scoot chair was ""all the way up"". She further stated, ""I sometimes put pillows behind his back."" The SPL walked over to the chair and raised up the backrest. The resident's medical record, when reviewed at 1:30 p.m. on 07/02/09, revealed a physician's for the scoot chair. A dietary note, dated 06/12/09, reported the resident consumes 59% of meals and requires supervision with meals. .",2014-04-01
11365,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,240,B,,,MWZ111,"Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resident #108 was dependent on staff for all ADLs except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. d) Resident #57 Record review revealed Resident #57 was dependent on staff for all ADLs. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. The water pitcher contained the same amount of liquid, nearly empty, at each check. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. .",2014-04-01
11366,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,252,D,,,MWZ111,"Based on observation and staff interview, the facility failed to provide a clean environment free from unpleasant odors as evidenced by the presence of a persistent odor of urine in a room shared by two (2) incontinent residents. This was evident for two (2) of four (4) sampled residents. Resident identifiers: #6 and #108. Facility census: 102. Findings include: a) Residents #6 and #108 share a room. Observations of the residents' shared room on 06/30/09, at 8:05 a.m., 1:42 p.m., and 2:15 p.m., revealed an unpleasant odor of urine that could be detected immediately upon entering the room. At 8:05 a.m., the odor seemed to be the strongest from Resident #6. At 1:42 p.m., the odor seemed to be coming from an afghan on the bed and the curtain separating the two (2) residents. At 2:15 p.m., the odor of urine was noted also from the wheelchair pad belonging to Resident #108, who had been sitting in the wheelchair. On all three (3) instances, the smell of urine was easily noticeable and could be detected immediately upon entering the room. On 07/01/09 at 11:45 a.m., the distinct odor of urine was detected immediately upon entering the room. During an interview at this time, a nursing assistant (Employee #93) stated she and other aides had noticed a bad smell in the room yesterday and, subsequently, Resident #108's mattress was changed. After the floor was mopped and the resident was showered, they still noticed the odor. She stated she did not believe the odor was coming from the pad in Resident #108's wheelchair, but she agreed she could smell the odor of urine in the curtain separating the residents. She immediately notified housekeeping. The housekeeping, upon arrival, smelled the curtain and also agreed it smelled like urine. She said they do terminal cleaning once every month, which includes taking down the curtains and washing them. She said Resident #6 will yell and throw things when that curtain is removed, as she always wants it pulled. She related she would use the second curtain in the room as a divider between the two (2) beds and take the malodorous curtain down and wash it today. .",2014-04-01
11367,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,242,D,,,MWZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, policy review, staff interview and record review, the facility failed to ensure one (1) of twenty-eight (28) Stage II sampled residents receive bi-weekly showers per resident request. Resident #133, who had an intestinal infection, reported she did not receive bi-weekly showers as requested, due to facility's infection control policy regarding [MEDICAL CONDITIONS] infection. Resident identifier: #133. Facility census: 102. Findings: a) Resident #133 Resident #133, when interviewed on 06/30/09 at 10:00 a.m., reported she has not been able to take a shower and get her hair washed for the past two (2) weeks. The resident stated she has an intestinal infection, and staff told her she could not take a shower due to the infection. Resident #133 stated, ""This makes me feel dirty and my hair looks terrible."" The director of nurses (DON - Employee #20) provided a copy of the facility's policy titled ""[MEDICAL CONDITION] Protocol"" on 07/01/09. Review of this, at 1:45 p.m. on 07/01/09, found no limitations on a resident's shower schedule during active infection. On 06/30/09 at 11:00 a.m., a licensed practical nurse (LPN - Employee #127), when interviewed, stated, ""Residents with [MEDICAL CONDITION] do not get showers due to loose stools."" On 07/01/09 at 2:45 p.m., the DON stated residents with [MEDICAL CONDITION] infection can have showers, and it is not the facility's policy to hold showers for residents with [MEDICAL CONDITION] infection. The DON further stated she needed to educate her staff regarding the current policy. Resident #133's medical record, when reviewed on 07/01/09 at 3:00 p.m., revealed a care plan for diarrhea dated 06/09/09. The interventions listed did not include withholding showers until the intestinal infection resolved. .",2014-04-01
11368,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,431,E,,,IFJQ11,"Based on an observation and staff interview, the facility did not ensure that two (2) of two (2) treatment carts were entered only by authorized personnel. A nursing assistant was permitted to have a key to open both treatment carts, which contained supplies and topical medications prescribed to residents by the physician. Facility census: 53. Findings include: a) An observation, on 03/18/09 at 10:00 a.m., revealed a nursing assistant (NA) was assisting the treatment nurse with resident treatments on 200 hall of the facility. The NA was observed using a key to enter the treatment cart and remove treatment supplies. An interview the NA, on 03/18/09 at 10:30 a.m., revealed she assisted the treatment nurse and was permitted to have a key to open both treatment carts. She also stated she would retrieve the necessary supplies and treatments (which would include physician-ordered topical medications) for the nurse. .",2014-04-01
11369,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,225,D,,,IFJQ11,"Based on facility record review and staff interview, the facility failed to make reasonable efforts to uncover criminal histories of two (2) sampled employees, by failing to conduct criminal background checks in all States in which these employees had previously worked. Employee identifiers: #1 and #4. Facility census: 53. Findings include: a) Employee #1 A review of the personnel file of Employee #1, who was hired on 01/21/08, revealed she possessed a nursing license from the Commonwealth of Pennsylvania, and information on her her employment application indicated prior work history in that State. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. b) Employee #4 A review of the personnel file of Employee #4, who was hired on 12/23/08, revealed prior work history in the State of Ohio. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. .",2014-04-01
11370,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,314,G,,,IFJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident sitting in a chair in front of the nurse's station; at 2:15 p.m., staff assisted the resident to bed to be seen by the physician. The chair in which the resident sat was wooden with a curved back and a small flat cushion built onto the chair seat. Review of physician's orders [REDACTED]. On 03/18/09 at 11:30 a.m., observation again found the resident sitting in the wooden chair in front of the nurse's station. During a subsequent interview at 12:05 p.m. on 03/18/09, the treatment nurse (Employee #80) was asked if the small flat cushion which was built onto the resident's chair was adequate as a pressure relieving device, and she stated it was not adequate. .",2014-04-01
11371,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,329,D,,,IFJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure the medication regimen of one (1) of ten (10) sampled residents was free of unnecessary drugs. Resident #21, who was receiving 2 mg a day of [MEDICATION NAME] (greater than the maximum daily dosage recommended for geriatric residents), was exhibiting no behaviors for which the medication was originally ordered, had the medication held on several occasions due to sleeping, and had no attempted gradual dose reduction for ten (10) months. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 A review of the resident's medical record indicated this [AGE] year old female was admitted to the nursing facility on 05/07/08, with a physician's orders [REDACTED]."" The resident continued to the present to receive the original dose [MEDICATION NAME] 0.5 mg four (4) times a day, for a total of 2 mg a day. A review of the facility's behavior record indicated that, for the months of February 2009, January 2009, December 2008 , November 2008, and October 2008, the resident did not exhibit any behaviors. The behaviors identified on this record for monitoring included agitation over need to leave and exit-seeking behavior. A review of the physician's progress notes revealed that only one (1) entry addressing the [MEDICATION NAME], dated 11/25/08, in which the physician indicated, ""Continue [MEDICATION NAME] less overall anxiety and less of a fall risk at present."" Observations of the resident, on 03/11/09 at 3:30 p.m. and 03/12/09 at 11:00 a.m., revealed the resident sitting in a wheelchair with the staff moving the resident to other locations in the facility. An observation of the resident, on 03/16/09 at 10:30 a.m.. revealed the resident lying in bed sleeping. Later at 2:30 p.m., the resident was again observed lying in bed sleeping. A nursing note, dated 02/26/09 (no time was documented), indicated the resident was lethargic related to not sleeping most of the night. The resident's [MEDICATION NAME] was held for the 1:00 p.m. dose. On 02/27/09 at 9:00 a.m., a nursing note indicated the resident was sleeping and the breakfast tray was held. On 03/01/09 at 9:00 a.m., a nursing note again indicated the resident was sleeping and the breakfast tray was held. A review of the CMS Appendix N for unnecessary medication revealed the recommended daily dose for the geriatric resident for the short acting benzodiazepine drugs ([MEDICATION NAME]) was 0.75 mg. A gradual dose reduction should be attempted at least twice within one (1) year. Resident #21 was receiving 2 mg a day and with no attempted dose reduction for ten (10) months. .",2014-04-01
11372,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2010-12-11,371,F,,,RUPW11,". Based on observation and staff interview, the facility failed to assure that two (2) male dietary aides wore effective hair restraints to prevent potential contamination of food by facial hair. This unsanitary practice had the potential to affect all residents receiving an oral diet. Facility census: 80. Findings include: a) An inspection of the dietary department, during the noon meal on 12/11/10 at 12:20 p.m., noted one (1) male dietary aide (Employee #3) was assisting with the service of the noon meal. Observation found Employee #3 had approximately 1/2 inch hair growth on his lip and chin with no beard guard in use to prevent his facial hair from potentially contaminating the food being served. Further observation found another male dietary employee (Employee #4) making peanut butter and jelly sandwiches in an adjacent room. Observation found Employee #4 had facial hair on his lip, chin, and along his jaw with no beard guard in place. When asked why he was not wearing a hair restraint on his beard and mustache, he stated that he had only worked there about three (3) weeks and had never been told he needed to wear anything on his face.",2014-04-01
11373,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-01-13,441,E,,,JK1V11,". Based on observation, staff interview, and a review of the facility's handwashing policy and procedures, the facility failed to ensure four (4) of nine (9) nursing employees observed washed their hand in accordance with acceptable hand hygiene practices per the facility's handwashing policy. Employees #102, #27, #71, and #155 were observed to turn off the faucet with their hands before drying their hands and without obtaining a clean paper towel to turn off the water. This had the potential to affect any resident receiving care from these employees after their hands became recontaminated from contact with the water faucet. Resident identifiers; #39, #115, #36, and #22. Facility census: 132 Findings included: a) Employee #102 During observations made on 01/12/11 at 1:30 p.m., a registered nurse (RN - Employee #102) was observed while washing her hands and after providing perineal care to Resident #39. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for two (2) of three (3) handwashing observations for this employee. -- b) Employee #27 During observations made on 01/12/11 at 1:45 p.m., a nursing assistant (Employee #27) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) of two (2) handwashing observations for this employee. -- c) Employee #71 During observations made on 01/12/11 at 1:45 p.m., a licensed practical nurse (LPN - Employee #71) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) observation for this employee. -- d) Employee #155 During observations of incontinence care on 01/12/11 between 3:10 p.m. and 3:40 p.m., a nursing assistant (Employee #155) was observed assisting with the care of Residents #36 and #22. She washed her hands, turned off the sink faucet with her hand, and then proceeded to dry her hands with a paper towel and put it in the trash. -- e) Review of the facility policy / procedure on handwashing (dated 01/20/10) revealed, in Section C, Item #3, that after washing hands, staff was to use a paper towel to turn off the faucet. -- f) During an interview on 01/13/11 at 10:30 a.m., the director of nursing (Employee #171) reported her expectation that all employees were to follow the facility's handwashing policy and procedure and use a paper towel to turn off the faucet.",2014-04-01
11374,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-01-05,257,E,,,TDRO11,". Based on observation, confidential family interview, confidential resident interviews, and staff interview, the facility failed to maintain an environment with temperatures that were comfortable for the residents. Residents expressed that it was often cold in the front hallway area of the facility that leads to the outside. This was an area frequented by residents and visitors, and persons had to pass through this area to access the activity room, the dining area, and the therapy room. The uncomfortably cold temperature of this area had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During a tour of the facility on 01/03/11 beginning at 1:00 p.m., the temperatures in different areas of the facility were measures, and all areas were found to be above 72 degrees Fahrenheit (F) except the front lobby. The maintenance supervisor (Employee #3) was asked to place a thermometer in this area, so the temperature could be monitored in the hall. Using the facility's own thermometer, the temperature in that hallway at that time was 68 degrees F. Observation also found the heater on the hall in that area was not turned on at that time. - A confidential family interview, conducted on the afternoon of 01/03/11, revealed the facility's temperatures fluctuated a lot, and it was often very cold in this hallway. She stated her mother, who often sites in the hallway, gets very cold, and staff does put a blanket on her, but she would feel the end of her mother's nose and find it to be ""cold as ice"". - Confidential interviews with alert and oriented residents identified six (6) residents who felt the ambient temperature of this area was uncomfortably cold. One (1) resident stated, ""When it is real cold outside, you can not hardly stand to come through that area, but you have to go through it to get to the dining room. Then you are cold when you get in the dining room, because you came through that cold air."" Another resident commented that it was very cold in the area when it is real cold outside. One resident said it was cold there and she just tried to hurry through that area and hoped that nothing slowed her down when it is cold. Another resident reported her room was nice and warm, and sometimes she doesn't want to come up front, because she has to go through that cold area. ""Sometimes you have a hard time getting through if it is congested, and there are a lot of people in that area. She stated, ""Sometimes there's a lot of action going on in that area, and you can't get through very fast."" She did not like to linger in that area because of the cold temperature. - Observations of the front lobby area, from 01/03/11 to 01/05/11, found the door was opened very frequently for visitors, the ambulance, and for some deliveries. On the days of the observations and interviews, the exterior temperature was 41 degrees F, while the interior temperature of this area only got up to 68 degrees F. - During an observation on 01/04/11 at 10:00 a.m., Resident #14 was found sitting in front hallway. This resident was dependent on the staff for mobility, and staff had parked her in the front hallway in her wheelchair. At 10:01 a.m., the temperature of the resident's room, where she had been before being brought to the front hallway, was found to be 80 degrees F. Resident #14 was transported from a room measuring 80 degrees to the front hallway measuring 68 degree F. Resident #14 was observed sitting in this hallway until 11:15 a.m. She did have a blanket laying over her, but the air was still cool to breathe and cool on her face after having previously been in a really warm room. This resident was confused and did not communicate; she could not have told staff that she was cold or ask anyone to move her to another area. - During an interview with Employee #3 on 01/04/11, he verified this area was only warmed up to 68 degrees F with the extra wall heater running. He also verified that, when it was really cold outside, this area was difficult to keep warm, and this was where the residents liked to sit. He verified that, with only one (1) single door in this area leading to the outside, when it was outside outside of the facility, this hallway would get cold every time the door was opened. .",2014-04-01
11375,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-01-05,323,D,,,TDRO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure the resident environment was free of accident hazards, by applying elevated half side rails to the bed of one (1) of seven (7) residents without first determining these half rails were necessary and safe for use. The facility assessed Resident #43 for the need for side rails on his bed, and his most recent assessment revealed the use of side rails was not indicated. The resident was observed, on 01/05/11, to have half side rails up. This resident was confused, he required staff assistance with transfers and mobility, and he had a history of [REDACTED]. Resident identifier: #43. Facility census: 57. Findings include: a) Resident #43 Observation of Resident #43, on 01/05/11 at 10:00 a.m., found him in bed with a half side rail in the elevated position. The nursing assistant (NA - Employee #29) caring for Resident #43 was interviewed at 10:05 a.m. on 01/05/11, regarding the use of side rails on this resident's bed. This employee stated Resident #43 used side rails to turn and reposition himself in bed. When asked how she determines who was suppose to use bed rails, she stated that the rails were secured down and could not be raised on the beds of residents who were not to use the rails. Review of Resident #43's medical record found a side rail assessment completed on 11/01/11. This assessment indicated the resident did not meet the criteria for the use side rails. Further review of the medical record revealed his [DIAGNOSES REDACTED]. In an interview at 1:00 p.m. on 01/05/11, the director of nursing (DON - Employee #70) identified that Resident #43 should not have side rails used on his bed. She stated that he was confused and he was not supposed to have side rails. She verified the assessment completed on this resident showed that side rails were not indicated for this resident and, therefore, the side rails should not be used.",2014-04-01
11376,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,157,D,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the electronic medical record, staff interview, family interview, and incident report review, the facility failed to immediately inform the legal representative when one (1) of nine (9) sampled residents was involved in an incident requiring physician intervention. Resident #100, who had a history of [REDACTED]. After the son intervened, staff contacted the physician and Resident #100 was subsequently sent to the hospital where she was diagnosed with [REDACTED]. Facility census: 115. Findings include: a) Resident #100 On 11/16/10 at approximately 9:00 a.m., a family interview revealed Resident #100's son, who was also her legal representative, did not receive notification that his mother fell on [DATE] until he came to the facility on [DATE] and found a bruise on her shoulder. - Documentation on an incident report dated 10/16/10, when reviewed on 11/16/10 at approximately 1:00 p.m., revealed the nurse wrote, ""As I was starting up the hallway, to do my med pass heard resident in (room #) yelling out. When entered the room and walked to her side (sic) she already started out of the bed on her arms before I got to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side."" Documentation on the report related to notification of the resident's responsible party found the son was not notified of the fall until 5:00 p.m. on 10/17/10. - Review of Resident #100's electronic medical record, on 11/16/10 at approximately 2:00 p.m., revealed a nursing progress note identified as a ""late entry"" and dated 10/16/10 at 21:00 (9:00 p.m.) which stated, ""As I was walking up the hallway to do my med pass. Writer heard resident yelling out. When entered the room and walked to her side. She already started out of the bed on her arms before I could get to her; the bottom half slithered out and onto the mat. Asked resident if she could get up and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist resident back into bed. When I had given the resident her meds which I had already had in the room with me at that time (sic). I assessed and did not see any injuries at this time. Resident did not complain of any pain nor distress noted."" A nursing progress note dated 10/17/10 at 18:20 (6:20 p.m.) stated, ""At 5pm (sic) son reported to this nurse that he found a bruise on resident's shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray. B/P 123/69 Temp 98.6 R18 P87 O2 sats 95%. Called Life Ambulance but had no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - A nursing progress note dated 10/17/10 at 23:46 (11:46 p.m.) stated: ""Resident returned to facility at this time, via ambulance stretcher alone, family did not accompany her at this time, received report from d/c nurse at (name of hospital), she stated she has a FX (fracture) to her right clavicle and will be returning with an immobilizer to right arm...."" - On 11/17/10 at approximately 1:00 p.m., the administrator and director of nursing agreed the facility should have contacted the resident's son on 10/16/10 after the fall occurred. .",2014-04-01
11377,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,441,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the facility failed to fully implement appropriate measures to control the spread of scabies and to prevent possible re-exposure and re-infestation, in accordance with the facility's infection control policies and procedures and accepted standards of professional practice. These practices had the potential to result in more than minimal harm to all residents. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the handling of an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: ""To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: ""Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. ""Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..."" (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients: "" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): ""Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]."" (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) .",2014-04-01
11378,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,490,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the governing body failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical well-being of all residents and others. The facility's administration failed to oversee and ensure the infection control policies and procedures were implemented as written to manage an outbreak of scabies and prevent transmission to others inside and outside the facility. This practice has the potential to cause more than minimal harm to all residents, staff, and visitors. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the governing body's failure to ensure the facility responded appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: ""To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: ""Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. ""Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..."" (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients: "" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): ""Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]."" (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) .",2014-04-01
11379,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,520,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients:"" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) In a written statement provided by the DON on 11/17/10, the facility held their last quarterly QAA committee meeting on 07/02/10. During that meeting, the committee discussed the procedures to be taken in a scabies outbreak. One (1) item listed on the written statement was that the facility would bag all items in resident rooms, label, and date them for when the bags are to be opened. The facility did not list a monitoring action to ensure that all procedures were implemented during a scabies outbreak.",2014-04-01
11380,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,309,G,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have ""slithered"" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a ""late entry"" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising was discovered by the family. This bruise, which extended from her neck, across her shoulder, and down her right arm, was readily visible to the family (as the resident was wearing a hospital gown), and it was turning black in color when found by the family on 10/17/10. The facility had no knowledge of this bruise until the family brought it to their attention. Only after the son intervened, did the facility contact the physician, and Resident #100 was later diagnosed with [REDACTED]. Although it could not be ascertained whether the fracture was sustained during the fall on 10/16/10, during the transfer back to bed after the fall on 10/16/10, or during a fall that occurred at an earlier date, the facility failed to identify the presence of the injury and obtain medical intervention until after the resident's family intervened. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, ""As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)."" This report, which was signed as having been prepared by Employee #128 on 10/16/10, contained no assessment information in the section titled ""Initial Assessment"", which prompted the assessor to record information such as vital signs and an examination for any changes in the resident's range of motion. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - ""Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve."" - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a ""late entry"", written by Employee #128, an LPN - ""As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted."" - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - ""At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - ""resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..."" There were no entries between the note identified as a ""late entry"" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. -- 3. A review of the nursing notes after the resident's return to the facility on [DATE] revealed an entry dated 10/18/10 at 08:47 (8:47 a.m.), written by Employee #34, stating, ""Late entry for 10/17/2010. During med pass at 10am (sic) this nurse ask (sic) resident if she was having any pain. Resident denied pain. Resp (respirations) even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed dose of Tylenol (sic) and ask (sic) resident again if she had any pain and she denied pain. Administrated schelduled (sic) medication at 2:30pm (sic) and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Ask (sic) resident how if (sic) she was feeling ok and she stated she was 'fine'."" All of this information was entered into the record on the morning after the resident returned from the hospital, after having been diagnosed with [REDACTED]. -- 4. review of the resident's medical record revealed [REDACTED]. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers), and a test for standing balance could not be attempted at that time. Review of the resident's care plan revealed a problem statement related to the resident's risk for complications associated with diabetes. The first intervention listed to address this problem was: ""Assess skin integrity daily with care and report abnormalities."" Review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: 10/16/10 on evening shift - total dependence for transferring by two (2) nursing assistants; total dependence with bathing (partial bed bath); extensive physical assistance with dressing by two (2) nursing assistants; and total dependence for personal hygiene by one (1) nursing assistant. 10/16/10 on night shift - extensive physical assistance for transferring by two (2) nursing assistants; extensive physical assistance for bathing by two (2) nursing assistants (sponge / bed bath); and total dependence with dressing by one (1) nursing assistant. No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and no information was available any ADL assistance provided on the evening shift, because staff recorded ""OOF"" (out of facility) for the entire shift, even though the resident was not transferred to the hospital until 6:20 p.m. on 10/17/10. (See also citation at F514.) The performance of transferring, dressing , bathing, and/or personal hygiene on these shifts for this dependent resident would have provided opportunities for staff to have observed bruising as it developed on the resident's right neck, shoulder and upper arm, especially while she was wearing a hospital gown (as had been observed by the family on the evening of 10/17/10). -- 5. Review of an ""unusual occurrence"", self-reported by the administrator to the State survey and certification agency on 10/18/10, revealed the following: ""On 10/17/10 MPOA of (Resident #100) had a concern about the bruise on her left shoulder and questioned if it was fractured. The administrator was notified by the MPOA that he needed to see it. (Note: The reference to the left shoulder appears to be a mistake as the nursing note for 10/17/10 reflected the son found a bruise on the resident's right shoulder.) ""The Resident (sic) is DNR (do not resuscitate), limited treatment, Hospice. Has a history of multiple falls related to behavior issues (sic). According to physician determination of capacity, the resident lacks capacity to make her own healthcare decisions due to Dementia, Stage 7. ""On 10/16/10 at approximately 9:00pm (sic) the resident was observed to have been 'slithering out and onto the mat. Asked resident if she could get up and as she attempted went down onto her right side. Resident was assessed and the nurse did not see any injuries at this time. Resident did not complain of any pain nor distress noted. (No quotation mark was present to indicate where the quoted material ended.) ""During med pass at 10am (sic) on 10/17/10, the nurse asked resident if she was having any pain. Resident denied pain. Respirations were even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed does of Tylenol and ask resident again if she had any pain and she denied pain. Administered scheduled medication at 2:30 pm and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Asked resident if she was feeling ok and she stated she was 'fine.' ""On 10/17/10 at approximately 5:30pm (sic) the family visited and voiced concerns and wanted her to be sent to the Hospital (sic) for an evaluation. The Clavicle (sic) was fractured. The resident was returned to the facility with continued meds. Resident is being observed and monitored."" -- 6. A telephone interview with the administrator, on 12/08/10 at approximately 9:30 a.m., revealed Resident #100 received hospice services. She had a physician's orders [REDACTED]."" According to the administrator, Hospice Care had ordered this, because the family felt the multiple falls the resident was having may have been related to her having untreated pain. The administrator also said he had observed the resident, after the family contacted him on the evening of 10/17/10, and did not find her to be in any pain. -- 7. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. (See also citation at F157.) -- 8. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED].#100 had the following documented events in the days prior to 10/16/10: - 10/01/10 at 6:45 p.m. - ""Resident was in shower room with CNA when CNA attempted to stand resident to dry her off. When CNA was drying resident, resident decided to sit on floor. Resident was lowered to floor by CNA."" - 10/10/10 at 3:00 p.m. - ""Resident sitting in WC (wheelchair); went to stand up to go to room. She went down to the floor."" - 10/11/10 at 10:30 a.m. - ""Resident sitting in w/c (wheelchair) in hallway by nurses (sic) station - noted to roll out of w/c to floor."" - 10/11/10 at 11:15 a.m. - ""Resident noted to be scratching at right forearm then scab noted in hand - bleeding noted from right forearm."" - 10/11/10 at 3:00 p.m. - ""Resident found curled up on safety mat next to bed. Stated 'I'm hiding they are going to kill me.' When asked if she fell or climbed she stated she climbed to hide from people trying to kill her. "" - 10/12/10 at 8:45 a.m. - ""Pt (patient) was sitting in wheelchair in dining room requesting to 'go to Bed'. Pt was informed it would be a few minutes. Then pt leaned forward and fell on to floor."" - 10/13/10 at 5:15 p.m. - ""Resident was sitting at nurses (sic) station in w/c when resident put herself in the floor. When asked why she stated she was hiding cause (sic) they were gonna kill her."" The director of nursing (DON) reported, at about 11:45 a.m. on 12/09/10, that most of the time Resident #100 did not have any injuries from these incidents but that bruising would appear later. -- 9. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had ""slithered"" the bottom half of her body onto the mat. Following this, she went to get assistance from two (2) nurse aides (Employees #29 and #129). Employee #128 reported she believed the three (3) of them used a sheet to transfer the resident back into her bed; however, she was not positive that this was how the transfer back to the bed occurred. Employee #128 stated she did not consider this event a ""fall"" and, as a result, she did not complete an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) (NOTE: According to Appendix PP of the State Operations Manual promulgated by the Centers for Medicare & Medicaid Services, ""'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred."") Employee #128 commented that she guessed she just forgot to fill out the top initial assessment portion on the report. This section was left blank. She said she asked the resident if she was hurt, and the resident said she was not. She also said she asked the resident if she was in pain, and the resident denied that as well. Employee #128 said she had a concern that the resident may have injured her hip. This concern was due to the fact that she had asked the resident if she could get up after the fall and the resident tried but landed on her right side. The LPN said she assessed the resident's right hip by applying pressure to the area to see if the resident expressed experiencing pain; the resident did not. She denied physically assessing any other part of the resident's right side, and she did not perform any range of motion exercise to any areas on the resident's right side to check for injuries. Employee #128 said she was aware the resident had a bruise to her right shoulder from a previous fall. -- 10. Employee #129 was interviewed by telephone at approximately 1:00 p.m. on 12/09/10; he no longer worked at the facility. He confirmed that he assisted the LPN with getting the resident back to bed on 10/16/10; he said he thought they picked the resident up under her arms to get her back into bed. He reported having no other knowledge of anything pertaining to the fall. -- 11. Employee #34 was interviewed by telephone on the early afternoon on 12/09/10. She acknowledged she was the LPN assigned to work with Resident #100 on 10/17/10, and that she was at the facility when the resident's family arrived and questioned the bruise on the resident's shoulder. She reported she did not know how the bruise got there, but she told the family she thought the resident had fallen on 10/15/10. She stated she told the family they would probably get faster results from having a mobile imaging company perform the x-ray on the resident's shoulder but the family insisted on having the resident sent out to a local emergency room . She related that Employee #128 did not tell her anything about the resident falling on 10/16/10 when she reported to work at 7:00 a.m. on 10/17/10. Employee #34 said Resident #100 acted very pleasant on during the day on 10/17/10. She reported she always asks the residents if they are in pain and said Resident #100 denied being in pain. -- 12. The DON and administrator acknowledged that Employee #128 failed to thoroughly assess Resident #100 following the fall on 10/16/10. However, the DON and administrator reported their beliefs that the facility had provided quality care to the resident and that staff had mainly failed to document their assessments and findings .",2014-04-01
11381,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,514,D,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the medical record of one (1) of nine (9) sampled residents was maintained in accordance with accepted standards of professional practice. Resident #100 was observed by a licensed practical nurse (LPN) having ""slithered"" out of her bed and onto the floor on the evening of 10/16/10. The LPN who witnessed this occurrence (Employee #128), when interviewed on 12/09/10, reported that she did not record an entry in the resident's nursing notes when the event occurred; rather, she recorded an entry in the nursing notes after the family noticed extensive bruising on the resident's shoulder during a visit on the evening of 10/17/10. The note, which was identified as a ""late entry"" and dated 10/16/10 at 21:00 (9:00 p.m.), did not contain any information to alert the reader that it was actually recorded after the fact, at a later date and time. Additionally, review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed blanks where the assigned nursing assistant should have recorded the amount of ADL assistance provided to the resident on the day shift (7:00 a.m. to 3:00 p.m.) on 10/17/10, and staff recorded ""OOF"" (out of facility) for the evening shift (3:00 p.m. to 11:00 p.m.) on 10/17/10, even though she did not leave the facility until 6:20 p.m. on that date. According to this resident's most recent minimum data set assessment, she was totally dependent on staff for all ADLs. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, ""As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)."" This report was signed as having been prepared by Employee #128 on 10/16/10. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - ""Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve."" - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a ""late entry"", written by Employee #128, an LPN - ""As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted."" - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - ""At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - ""resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..."" There were no entries between the note identified as a ""late entry"" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. (See also citation at F309.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled ""5. Legal Documentation Standards"": ""9. Completeness - Document all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment (including the reason for it). Make sure entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification."" - ""20. Incidents - When an incident occurs, document the facts of the occurrence in the progress notes. Do not chart that an incident report has been completed or refer to the report in charting."" -- 3. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. -- 4. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED]. on 10/16/10 contained no information to alert the reader that the note was not contemporaneously recorded in the electronic medical record at 9:00 p.m. on 10/16/10. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had ""slithered"" the bottom half of her body onto the mat. Employee #128 stated she did not consider this event a ""fall"" and, as a result, she did not record an entry in the resident's medical record or generate an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled ""5. Legal Documentation Standards"": ""3. Date and Time on Entries ""3.1. Timeliness of Entries - Entries should be made as soon as possible after an event or observation is made. An entry should never be made in advance. If it is necessary to summarize events that occurred over a period of time (such as a shift), the notation should indicate the actual time the entry was made with the narrative documentation identifying the time events occurred if time is pertinent to the situation. ""3.2. Pre-dating and back-dating - It is both unethical and illegal to pre-date or back-date an entry. Entries must be dated for the date and time the entry is made. (See section on late entries, addendum, and clarifications). If pre-dating or back-dating occurs it is critical that the underlying reason be identified to determine whether there are system failures. The cause must be evaluated and appropriate corrective action implemented."" - ""24. Omissions in Documentation - At times it will be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement entries previously written. ""0. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ""1. Identify the new entry as a 'late entry'. ""2. Enter the current date and time - do not try to give the appearance that the entry was made on a previous date or an earlier time. ""3. Identify or refer to the date and incident for which (sic) late entry is written. ""4. If the late entry is used to document an omission, validate the source of additional information as much as possible (where did you get information to write late entry). For example, use of supporting documentation on other facility worksheets or forms. ""5. When using late entries (sic) document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes."" -- 5. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, and she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers). Review of the resident's ADL flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: - No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and - No information was available any ADL assistance provided on the evening shift, because staff recorded ""OOF"" (out of facility) for the entire shift. This dependent resident was not transferred to the hospital until 6:20 p.m. on 10/17/10 and would have been present to receive ADL assistance from staff throughout the entire day shift and a portion of the evening shift on 10/17/10.",2014-04-01
11382,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,327,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to: (1) ensure a resident with a gastrostomy feeding tube received all 275 cc free water flushes in accordance with physician orders; (2) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic and ""Patient much more alert /p (after) NS (normal saline) Bolus."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Regarding Maintaining Fluid Balance and Monitoring of Urinary Output Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" - ""Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional."" -- Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident ' s needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift, although there was a physician's orders [REDACTED]. -- Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours."" Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, "" ...Urinary output >200cc at this time."" -- Review of the resident's ""Bedside Intake and Output Records"" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. .",2014-04-01
11383,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,224,G,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature"", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". ""Patient much more alert /p (after) NS (normal saline) Bolus."" In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. -- 3. Hospital #2 Records The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 ""History and Physical"" revealed under the heading ""History of Present Illness"": ""This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..."" ""In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission."" Under the heading ""Impressions"" were noted: ""1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..."" Under the heading ""Plans"" were noted: ""1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications."" - The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Elevated Temperatures (a) Vitals Summary Report (VSR) A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as ""High of 99.0 exceeded"". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- (b) Nursing Notes Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - ""Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor."" - 10/14/10 at 1:47 p.m. - ""Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted."" - 10/17/10 at 11:30 a.m. - ""REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted."" - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- (c) Medication Administration Record (MAR) Review of the resident's November 2010 MAR revealed staff initialed having administered ""Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)"" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- (d) Comparison of VSR, Nursing Notes, and MAR Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (1) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). All entries in the nursing notes between 11/04/10 and 11/16/10 were made by licensed practical nurses (LPNs). There was no evidence of any nursing assessment having been completed by an RN and recorded in the resident's nursing notes. Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. No labs were ordered during this period of intermittent fevers beginning on 11/04/10, in an effort to identify the infectious organism(s) and/or what antibiotic(s) would be effective in treatment. (According to labs collected at Hospitals #1 and #2, the resident had multiple infectious organisms at multiple sites (central line catheter tip, urine, blood, and at the insertion sites of his suprapubic catheter and gastrostomy tube), all of which were resistant to [MEDICATION NAME], meaning the [MEDICATION NAME] that was administered prior to the resident's transfer to Hospital #1 was ineffective in treating these infections.) The only entry made by an RN prior to his transfer to the hospital was recorded at 9:48 p.m. on 11/17/10. It contained no assessment information but stated the resident was transferred to the hospital ""unplanned"" for evaluation and treatment, after the physician was notified of a ""condition change"" at 2145 (9:45 p.m.), and an attempt was made to notify the resident's responsible party. -- (2) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - ""... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - ""... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (3) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (4) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" -- (5) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (6) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- (e) References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. ""... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. ""... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems - Have a new rash or bruises appear - Have pain with urination - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. - Have recently traveled to a third world country"" (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled ""Fever: First aid"": ""Fever is a sign of a variety of medical conditions, including infection. ""... Under the arm (axillary) ""Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. ""... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..."" (URL: ) -- (3) According to Drugs.com, in an article titled ""How To Take An Axillary Temperature"": ""What is it? ""An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. ""Why do I need to check an axillary temperature? ""An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... ""How do I use a digital thermometer? ""Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..."" (URL: ) -- (f) Facility Policy Review of the facility's policy titled ""3.5 Vital Signs"" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled ""Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration"" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- (g) Care Plans Addressing Vital Signs A review of the resident's care plan revealed the following: (1) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (2) Another problem statement was: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Vital signs q (every) shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the VSR found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 5. Fluid Balance / Hydration Status (a) Physician Orders Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" - ""Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional."" -- (b) Care Plan Addressing Hydration / Fluid Balance Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output",2014-04-01
11384,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,157,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, and review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature facility failed, for one (1) of five (5) sampled residents, to promptly notify the physician when the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a urinary tract infection [MEDICAL CONDITION]. Resident #28 completed his antibiotic therapy on 11/07/10 and began having intermittent fevers on 11/09/10. Staff did not notify the physician of this until 11/16/10. The resident, who was transferred to a hospital on [DATE], was subsequently diagnosed with [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 ""History and Physical"" revealed under the heading ""History of Present Illness"": ""This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..."" ""In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission."" Under the heading ""Impressions"" were noted: ""1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..."" Under the heading ""Plans"" were noted: ""1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications."" The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR indicated [REDACTED] From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. "" ... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "" ... Call your doctor right away if you are an adult and you: ... - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- 6. A review of the resident's care plan revealed the following: A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal included: ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) .",2014-04-01
11385,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,514,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to maintain clinical records for one (1) of five (5) residents (#28) in accordance with accepted professional standards and practices that are completed, accurately documented, readily accessible, and systematically organized. The facility failed to obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. readings for analysis, tracking, and trending of abnormal findings. The facility also failed to record on the medication administration record (MAR) each time Tylenol was given from an elevated temperature and failed to record on the reverse side of the MAR whether the medication was effective in reducing his temperature. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his minimum data set assessment (MDS 3.0), an abbreviated quarterly assessment with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10. Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as ""High of 99.0 exceeded"". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- 3. Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - ""Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor."" - 10/14/10 at 1:47 p.m. - ""Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted."" - 10/17/10 at 11:30 a.m. - ""REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted."" - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- 4. Review of the resident's November 2010 MAR revealed staff initialed having administered ""Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)"" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- 5. Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "" ... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "" ... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature - (b) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - (c) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. - (d) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration.",2014-04-01
11386,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,282,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, policy review, and staff interview, the facility failed to provide services to one (1) of five (5) sampled residents in accordance with the resident's comprehensive plan of care including physician orders, with respect to: monitoring vital signs; providing free water flushes as ordered; monitoring the resident's urinary output to ascertain whether it was necessary to irrigate the resident's suprapubic catheter; monitoring central line and ostomy sites for signs of infection; and providing dressing changes to the central line site as ordered. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a PEG tube), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident ' s care plan revealed the following: (a) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (b) Another problem statement was: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Vital signs q (every) shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the weights and vitals summary report found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 4. Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours."" Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, "" ...Urinary output >200cc at this time."" Review of the resident's ""Bedside Intake and Output Records"" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. -- 5. Review of a facility table titled ""Infusion Maintenance Table"" (with a revision date of 04/01/10), revealed dressing changes for non-tunneled central venous access devices (including [MEDICATION NAME] central lines) are to be performed twenty-four (24) hours after insertion, then weekly and PRN. (It should be noted that the facility used ""PICC line"" in documentation prior to his return to the facility on [DATE] to describe what a [MEDICATION NAME] central line.) -- Further review of the resident ' s care revealed: One (1) problem statement said: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Sterile dressing change per policy and prn (as needed)."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of Resident #28's treatment sheet, used for recording care provided to central-line catheters, found it was marked to indicate scheduled dressing changes were to be completed on 11/02/10, 11/09/10, and 11/16/10. The dressing change scheduled for 11/16/10 was not initialed by a nurse to indicate it had been completed, in accordance with facility policy and the resident's care plan intervention. Another intervention developed to achieve this goal was: ""Inspect site for signs of inflammation, phlebitis, or infiltration q shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was inspecting the site of the central line for signs and symptoms of infection in accordance with this care plan intervention. -- Another problem statement was: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Monitor skin around PEG tube site,skin (sic) care and dressing as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) - Review of the monthly recapitulation of physician's orders [REDACTED]. Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was routinely inspecting the site for signs or infection. -- An interview with the assistant director of nursing (ADON - Employee #9), on 12/20/10 at 4:00 p.m., confirmed the form utilized by staff to documented central line dressing changes was not initialed on 11/16/10, which was the date the dressing was due to be changed. She further stated the nursing staff apparently did not change the dressing. -- According to the Hospital #2 ""Discharge Summary"", when the resident was evaluated in the hospital on the early morning of 11/18/10, the ER physician found pus surrounding his suprapubic catheter and [DEVICE], and his [MEDICATION NAME] catheter tip tested positive for Staphylococcus epidermidis. .",2014-04-01
11387,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,279,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to develop a care plan to ensure a resident with a gastrostomy feeding tube and a suprapubic catheter, who had a history of [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic and ""Patient much more alert /p (after) NS (normal saline) Bolus."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Fluid Balance and Monitoring Urinary Output (a) Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" -- (b) Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the assessment and/or maintenance of the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident's needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift (although there was a physician's orders [REDACTED]. -- (c) An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. .",2014-04-01
11388,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,281,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature"", and policy review, the facility failed to provide services that meet professional standards of quality for one (1) of five (5) sampled residents (#28). Resident #28, who had a gastrostomy feeding tube and a suprapubic catheter and who had a personal history of urinary tract infections, exhibited an elevated temperature beginning on 11/04/10. On 11/05/10, staff contacted the physician, who ordered a 3-day course of antibiotics ([MEDICATION NAME]) via intramuscular injection (IM). Two (2) days after this first course of antibiotics ended, the resident began (on 11/09/10) to exhibit intermittent elevated temperatures; however, the staff did not promptly notify the physician of this. These temperatures were taken via axilla, which is usually 1 degree Fahrenheit (F) below a temperature taken orally; the temperatures were not monitored at the frequency specified in the resident's care plan; they were not consistently recorded in the same place in the medical record for ready access for analysis, tracking, and trending; and the staff did not always medicate with Tylenol when indicated. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "" PEG tube "" or "" [DEVICE] "" ), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. - The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- (b) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR (to indicate Tylenol was given for an elevated temperature), but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - ""... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - ""... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (c) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (d) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" -- (e) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (f) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- 4. References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. ""... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. ""... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled ""Fever: First aid"": ""Fever is a sign of a variety of medical conditions, including infection. ""... Under the arm (axillary) ""Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. ""... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..."" (URL: ) -- (3) According to Drugs.com, in an article titled ""How To Take An Axillary Temperature"": ""What is it? ""An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. ""Why do I need to check an axillary temperature? ""An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... ""How do I use a digital thermometer? ""Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..."" (URL: ) -- 5. Review of the facility's policy titled ""3.5 Vital Signs"" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled ""Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration"" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- 6. A review of the resident's care plan revealed the following: (a) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. .",2014-04-01
11389,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,278,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of resident assessment data and physician orders, the facility failed, for one (1) of five (5) sampled residents, to ensure each resident assessment accurately reflected each resident's health status and condition. Resident #28's primary source of nutrition was received via a gastrostomy tube, but his most recent abbreviated quarterly assessment did not identify the presence of this feeding tube. Facility census: 68. Findings include: a) Resident #28 Record review, on 12/20/10 and 12/21/10, included a review of the resident's assessments and physician orders. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. In Section G, the assessor noted Resident #28 was totally dependent on one (1) staff member for eating. In Section K, the assessor noted he did NOT receive any nutrition through tube feeding. Review of the physician's orders [REDACTED]. - ""Peg tube: Magna ports 20 Fr. 10cc - FYI - Change when dysfunctional. May use 18 fr 10cc or 20 fr 10cc."" This order was originally given on 07/29/09 - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" This order was originally given on 05/18/09. Review of the resident's most recent comprehensive assessment (MDS 2.0) with an ARD of 01/28/10 revealed, in Section K, the assessor did note the presence of a feeding tube, which was used to provide 76-100% of the resident's total daily calories and 2001 or more cc of fluid intake daily. .",2014-04-01
11390,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2010-12-29,329,D,,,CYQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to assure the resident's drug regimen was free of unnecessary drugs. A resident receiving a medication that had the ability to affect her level of consciousness, and which was ordered to treat the symptom of anxiety, was awakened by the nurse by having her face bathed with a cold cloth in order to receive an additional dose of that same medication. Resident identifier: #65. Facility census: 61. Findings include: a) Resident #65 When reviewed on 12/28/10, the closed medical record of Resident #65 divulged the resident had been admitted to the facility in February 2001 and was 80-years old at that time. When transferred to the hospital from the facility on 12/11/10, the resident's weight was noted to be 70 pounds. The resident was noted to have [DIAGNOSES REDACTED]. The resident's record further revealed she suffered with severe breathing problems and frequent episodes of anxiety, possibly associated with the inability to breathe without difficulty. The resident had been receiving the medication Klonopin for anxiety, in varying dosages since the time of admission to the facility. On 12/10/10, a physician's orders [REDACTED]. According to the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to http://www.fda.gov/downloads/Drugs/DrugSafety, the patient medication guide for the medication Klonopin indicated the most common side of the medication is drowsiness. Facility nurse's notes, on 12/11/10 at 10:50:57 a.m., stated, ""Klonopin 0.5mg given this am (morning) and resident very hard to awaken. Cold wash cloth applied to forehead and to resident's face. Resident aroused long enough to give meds. Also was unable to feed resident breakfast or to give am (morning) snack..."" The resident was not exhibiting the symptom of anxiety for which it was ordered, and she was actually experiencing a decreased level of consciousness prior to the administration of the dose (as stated in the 12/11/10 nurse's note). This documented statement would indicate the evening dose of the medication was unnecessary at that time. On 12/28/10 at approximately 4:00 p.m., the facility's director of nurses (DON), when questioned about this statement of the need to awaken a resident to administer an anti-anxiety medication, could provide no reason for a sleeping resident to be awakened to receive a medication prescribed to treat anxiety.",2014-04-01
11391,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-03-17,225,D,,,N9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to immediate report and/or thoroughly investigate allegations of abuse and/or neglect to the appropriate State agencies. This affected two (2) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94 and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as ""modified independence"" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They again denied having ever received complaints or allegations of neglect involving this resident. d) The faciltiy failed to acknowledge that complaints filed on behalf of Residents #94 and #96 contained allegations of abuse and/or neglect, failed to immediately report these allegations to State agencies as required, and failed to thoroughly investigate these allegations. .",2014-04-01
11392,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-03-17,165,D,,,N9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to support each resident's right to voice grievances and failed, after receiving a complaint or grievance, to actively seek a resolution and keep the resident or his or her representative appropriately apprised of the facility's progress toward resolution. This affected three (3) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94, #95, and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. A review of the facility's complaint policy, provided by the social worker on 03/16/10, revealed the following: ""ALL COMPLAINTS RECEIVED BY THE FACILITY MUST BE DOCUMENTED IN THE COMPLAINT LOG, KEPT AT THE CHART DESK ON THE A-SIDE."" ""ALL COMPLAINTS AND SOLUTIONS SHOULD BE MAINTAINED IN A FILE FOR FUTURE REFERENCES, AFTER A COPY HAS BEEN SUBMITTED TO THE ADMINISTRATOR."" b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #95 Review of Resident #95's closed record revealed an [AGE] year old male who was admitted to the facility on [DATE], and who was discharged to another nursing home on 03/01/10 at the request of his HCS, who was the DHHR case worker. Further review of the record revealed a nursing note, for the morning of 02/10/10, recording that the resident's daughter contacted the social worker to complain about not having been informed of the resident having been sent to the hospital emergency roiagnom on the previous day. The family learned about the transfer on 02/10/10 from the DHHR case worker who, according to the notes, had instructed the facility's social worker to keep the resident's family informed when he was sent to the hospital, even though they were not the resident's legal decision makers. Although there was documentation to reflect numerous phone calls made to DHHR regarding the resident's status, there was no evidence the family was informed when changes occurred in the resident's condition or treatment. At 5:00 p.m. on 02/10/10, the DON recorded in the resident's record that she had received a call from the WV State Police informing her the resident's family had complained that the resident had been sent to the hospital but the facility would not tell them where. During an interview with the social worker and the DON at 1:30 p.m. on 03/16/10, they stated they did not consider the above incident a complaint, because the family was not the resident's responsible person and had no right to complain. They stated that the only reason for the voluminous documentation in the chart was for ""legal reasons"". d) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as ""modified independence"" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter reported Resident #96 fell at the facility on 01/29/10, sustaining numerous bruises on her face, legs, hip, abdomen, and back and a laceration on her right calf; she was taken to the emergency room and returned to the facility. The daughter questioned facility staff about how the fall happened and was told it happened in the dining room, but she was never given any additional information. It was at this point the family member started making arrangements to care for her mother at home. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter reported that a motorized scooter was purchased for the resident's use, and the family was told the resident could use it after being taught how to safely do so by physical therapy. The therapist notified the family by phone the resident could not use the scooter, because he had been notified that she had run it into a wall. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. Record review found an incident / accident report, dated 01/29/10, which noted the resident had fallen while using her walker; documentation on the report confirmed injuries were sustained as a result of this fall. Documentation on the report also indicated the family was notified of the fall, but there was no mention on the report of the family having questioned the circumstances of the fall. Review of Resident #96's closed record found the only documentation about the scooter was a physical therapy note on 02/10/10, which recorded the resident was being evaluated for a scooter. There was no incident / accident report or other documentation about the resident running the scooter into a wall, and no one at the facility (including the physical therapist), when questioned by this surveyor, could remembered any incident involving the resident having done this. 4. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They also denied that anyone had ever complained about the resident not being allowed to use the scooter. They again denied having ever received complaints or allegations of neglect involving this resident. e) The facility failed to support each resident's right to voice grievances, by failing to register and respond to all complaints filed on behalf of Residents #94, #95, and #96 by their family members or legal representatives. .",2014-04-01
11393,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2010-12-07,323,G,,,EBZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have ""bruising each side of her nose"" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was ""slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)."" - On 11/25/10 at 8:30 p.m., a report stated, ""Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash."" - On 11/27/10 at 5:00 p.m., another report stated, ""CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted."" No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., ""CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..."" - On 07/29/10 at 6:00 a.m., ""Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct."" - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), ""Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..."" Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: ""Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms."" The goal associated with this problem statement was for this resident to ""wander safely and have no injuries r/t falls through review date."" Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. - 7. Resident #24, when asked if he was bothered by wandering residents during an interviewed 12/06/10 at 12:15 p.m., stated that yes he was and that Resident #20 had wandered into his room the previous night, taken his soft drink, and dumped it into the sink. When asked what he did in response, he stated that he ""took ahold of him (Resident #20)"" then a nurse came in and told him he couldn't do that. When asked if a barrier-type stop sign had ever been offered to him to deter wanderers from entering his room, Resident #24 stated, ""No."" - 8. Following the interview with Resident #24, the facility was toured and observation found only two (2) barrier-type stop signs in use on two (2) resident rooms, but the devices were not attached in a manner that would deter a wanderer; in both cases, the banners were hanging on one (1) side of the doorway instead of being secured across the doorways as intended. On the second day of the investigation (12/07/10), observation found three (3) such barriers in place. The third barrier was noted to be across the entrance to Resident #24's room. When interviewed again on 12/07/10 at 11:00 a.m., Resident #24 stated he asked staff for the barrier after speaking with this surveyor the previous day. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his ""head gashed open"". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found "" lying on floor with roll table over him."" Notes stated, ""Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall."" - On 10/11/10 at 9:30 a.m., the resident was ""found lying on fall mat in his room (sic) assisted back to bed."" - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. ""fell on R knee and R elbow."" - On 10/14/10 at 10:15 a.m., ""Resident exited facility through Activity Room Door. Brought back in without difficulty."" - On 10/19/10, ""Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor."" - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., ""Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor."" - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the ""grate"" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. ""Resident still had his support hose on."" - On 11/15/10 at 10:05 p.m., ""Heard resident yelling, found resident laying on the floor in resident's room."" The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. ""Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed."" - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, ""Not sure if (fall was) from bed or chair."" The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, ""Resident's bed alarm ringing and was on the floor skin tear to R (right) knee."" - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. Observation, at 2:34 p.m. on 12/07/10, found Resident #20 lying on his bed. There was no body alarm present in the room, and the bed alarm was disconnected. This observation was confirmed by the DON, who stated, ""It can't work if it's not connected."" - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to psychotropic drug use and he had the potential for ""adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care."" Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a head laceration to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: ""High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior."" The goal related to this problem statement was: ""Resident to remain safe, free from injury."" Approaches to assist the resident in attaining this goal included: ""Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed."" The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for ""no known reason"" and was noted to have said, ""I'm gonna give him one."" The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 ""punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye."" - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others.",2014-04-01
11394,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2010-12-07,280,D,,,EBZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to review / revise their care plans with new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Resident identifiers: #19, #20, and #36. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have ""bruising each side of her nose"" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was ""slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)."" - On 11/25/10 at 8:30 p.m., a report stated, ""Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash."" - On 11/27/10 at 5:00 p.m., another report stated, ""CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted."" No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., ""CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..."" - On 07/29/10 at 6:00 a.m., ""Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct."" - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), ""Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..."" Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: ""Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms."" The goal associated with this problem statement was for this resident to ""wander safely and have no injuries r/t falls through review date."" Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his ""head gashed open"". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found "" lying on floor with roll table over him."" Notes stated, ""Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall."" - On 10/11/10 at 9:30 a.m., the resident was ""found lying on fall mat in his room (sic) assisted back to bed."" - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. ""fell on R knee and R elbow."" - On 10/14/10 at 10:15 a.m., ""Resident exited facility through Activity Room Door. Brought back in without difficulty."" - On 10/19/10, ""Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor."" - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., ""Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor."" - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the ""grate"" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. ""Resident still had his support hose on."" - On 11/15/10 at 10:05 p.m., ""Heard resident yelling, found resident laying on the floor in resident's room."" The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. ""Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed."" - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, ""Not sure if (fall was) from bed or chair."" The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, ""Resident's bed alarm ringing and was on the floor skin tear to R (right) knee."" - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to [MEDICAL CONDITION] drug use and he had the potential for ""adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care."" Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a [MEDICAL CONDITION] to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: ""High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior."" The goal related to this problem statement was: ""Resident to remain safe, free from injury."" Approaches to assist the resident in attaining this goal included: ""Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed."" The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for ""no known reason"" and was noted to have said, ""I'm gonna give him one."" The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 ""punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye."" - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others. .",2014-04-01
11319,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-02-04,240,D,1,0,NKDJ11,". Based on record review, staff interview, and resident interview, the facility failed to assure one (1) of five (5) sampled residents received care in a manner that promoted or enhanced his quality of life, by failing to assure Resident #10 received assistance with toileting in a timely manner. Resident identifier: #10. Facility census: 113. Findings include: a) Resident #10 Review of the nursing assistant work sheets, on the evening of 02/03/11, noted that nursing staff had provided no information concerning the resident's nursing care needs. An interview with the nursing assistant (NA) assigned to care for this resident on the evening of 02/03/11 (Employee #37) was conducted at approximately 7:00 p.m. She was asked how she obtained the necessary information to provide nursing related services for Resident #10. Employee stated that nursing staff was supposed to place the information in the ""care card"" (Nursing Assistant Care Card) book. She relayed that Resident #10 did not have a care card for her to know how to provide care for him. She stated that, earlier that morning, Resident #10 had asked to be taken to the bathroom. She stated that she did not have the necessary information to transfer him safely and asked the licensed practical nurse (LPN - Employee #91) how the resident was to be transferred or taken to the bathroom. She stated the LPN told her, ""I don't know."" Employee #37 relayed that the resident had to wait until therapy could take him to the bathroom. In an interview with Resident #10 conducted at 1:20 p.m. on 02/04/11, he was asked to relay what he remembered about asking to go to the bathroom the previous morning. The resident was alert, oriented, and answered questions appropriately. Resident #10 stated that two (2) girls came into his room yesterday morning, and he asked them to take him to the bathroom. He stated he was told they would have to get some help, and they left the room. He stated he had to wait approximately twenty-five (25) minutes for assistance to the bathroom. He stated, ""There was no excuse for that."" .",2014-06-01
11320,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-02-04,279,D,1,0,NKDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and facility staff interview, the facility failed to develop a comprehensive care plan to meet the nursing needs of one (1) of five (5) sampled residents. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 1. Review of Resident #120's medical record found the resident was ordered by the attending physician to receive no foods or fluids by mouth (NPO) on [DATE]. Further review found Resident #120 exhibited food-seeking behaviors and frequently asked staff for food. A staff member gave the resident ice cream on the evening of [DATE]. Review of the care plan found no plan in place to address this resident's food-seeking behaviors. The care plan contained no interventions for staff members to utilize to redirect the resident when displaying these behaviors. An interview with the minimum data set (MDS) nurse (Employee #16), on the afternoon of [DATE], confirmed Resident #120's care plan did not contain interventions for nursing staff to utilize when the resident displayed food-seeking behaviors. 2. Review of the resident's medical record found a Physician order [REDACTED]. The POST form ordered that the resident did not desire cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Review of the care plan in effect during the resident's stay at the facility found that nursing staff was instructed to initiate CPR should the resident be found with no apical pulse, respirations, and/or blood pressure, contrary to information found on the resident's POST form. .",2014-06-01
11321,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-02-04,281,E,1,0,NKDJ11,". Based on staff interview, review of facility documents, resident interview, review of 10CSR Title 10 Legislative Rules State Board of Examiners for Licensed Practical Nurses, Series 3, 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"" (revised 06/17/09), the facility failed to assure that licensed practical nurses (LPNs) provided nursing related services in accordance with the legal standards of nursing practice and by the guidelines established by the West Virginia Boards of Nursing. The practice of this facility required LPNs to assign nursing related duties to nursing assistants (NAs) by direct communication and indirect communication via nursing assistant care cards (""care cards"") and nursing assistant work sheets (""assignment sheets""). Investigation revealed LPNs failed to communicate necessary care information to the NAs through these established forms of communication for four (4) of five (5) sampled residents. This deficient practice resulted in one (1) of five (5) sampled residents not receiving assistance with toileting in a timely manner, and had the potential to adversely affect an additional three (3) of five (5) sampled residents. Resident identifiers: #10, #74, #100, and #90. Facility census: 113. Findings include: a) Residents #10, #74, #100, and #90 1. During the entrance conference conducted at 5:00 p.m. on 02/03/11, a registered nurse (RN - Employee #32) was asked how NAs received instructions from the licensed nursing staff. Employee #32 stated the facility maintained a book of care cards with resident specific care information for the NA staff. She provided copies of the assignment sheets for the nine (9) NAs working the evening shift. Review of the assignment sheets found the assignment sheet provided to Employee #37 (an NA) contained only room numbers for three (3) residents (Residents #10, #74 and #100). When Employee #37 was asked which residents were in the listed rooms and what their care needs were, she was unable to provide the information requested. She stated that her assignment sheet was in this condition when it was given to her. She further stated that the care cards were not in the book in order for her to determine what care to provide for these residents. 2. Resident #10 Employee #37 relayed an incident that occurred that morning. She stated that she and another aide had entered Resident #10's room that morning, and the resident asked to go to the bathroom. She stated she did not know how the resident was to be toileted or transferred. She left the resident's room and relayed to a LPN (Employee #91) that Resident #10 requested to be taken to the bathroom, and she asked the LPN how he needed to be transferred. She stated the LPN told her, ""I don't know."" She stated the resident had to wait until therapy staff came to help him to the bathroom. Resident #10 was alert and oriented and able to answer questions appropriately. He was interviewed about the reported incident at 1:10 p.m. on 02/04/11. When asked to relay any memory he had of asking to go to the bathroom the morning before, he stated two (2) girls came into his room and he told them he had to go to the bathroom. He stated they told him they would have to get some help, and then they left the room. He stated he had to wait approximately twenty-five (25) minutes for someone to take him to the bathroom. He stated, ""There was no excuse for that."" The above findings were immediately reported to the director of nursing (DON), who initiated a neglect investigation. 3. Resident #74 Review of Resident #74's medical record found the attending physician ordered the resident's bed to be elevated 30 degrees to 45 degrees at all times for aspiration precautions. Employee #37 was not provided this critical care information by the LPN staff. 3. Residents #100 and #90 Review of the assignment sheets and care card books found that NAs were also not provided necessary resident-specific nursing care information by the LPNs for Residents #100 and #90. 4. Review of 10CSR Title 10 Legislative Rules State Board of Examiners for Licensed Practical Nurses, Series 3, under section 10-3-4, Standards Related to the Licensed Practical Nurse's Responsibilities as a Member of the Health Care Team found the following: Section 10-3-4.8 stated the following, ""retain accountability for the timely and accurate completion of tasks assigned to other qualified persons..."" Section 10-3-4.4 states the following, ""accept responsibility for individual nursing actions, competencies, and behavior..."" Section 10-3-3.3.4 states the following, ""assign components of nursing care to other qualified persons..."" -- Review of Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (revised 06/17/09) found the following: In the section entitled ""FIVE RIGHTS OF DELEGATION / ASSIGNMENT"" was found: ""...3. RIGHT DIRECTION / COMMUNICATION clear, concise description of the task, including its objective, limits and expectations. 4. RIGHT SUPERVISION Appropriate monitoring, evaluation, intervention, as needed, and feedback."" .",2014-06-01
11322,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-02-04,367,D,1,0,NKDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure one (1) of five (5) sampled residents received a diet as prescribed by the attending physician. Resident #120 was given ice cream when the physician ordered the resident receive nothing by mouth (NPO) due to risks of aspiration. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 Review of facility documents found a nursing assistant (NA - Employee #59) provided Resident #120 with ice cream for a bed time snack on the evening of 10/12/10. Review of the resident's medical record found the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The treating physician had ordered the resident to be NPO as of 11/01/10. An interview with the director of nursing (DON), on the afternoon of 02/04/11, confirmed the diet prescribed to Resident #120 by the attending physician was not followed.",2014-06-01
11323,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,364,B,0,1,IH3P11,"Based on observation and staff interview, the facility failed to provide food that was attractive in appearance for the evening meal on 02/09/09. The food items served during evening meal provided only white, brown, and yellow as colors on the resident trays. This had the potential to affect all residents who chose the main entree for dinner on 02/09/09. Facility census: 106. Findings include: a) Observation of the dinner meal, on 02/09/09 at 5:00 p.m., found the meal consisted of chicken nuggets, cauliflower, and hashbrown casserole, which were brown and white in color. Pineapple was the dessert and was yellow in color. The appearance of the items on the residents' plates offered no variety in color and texture. An interview with the dietary manager ,and a review of the menus on the late morning of 02/12/09, found that fruit ambrosia was supposed to have been on the menu for that day. .",2014-06-01
11324,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,371,F,0,1,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure pre-poured containers of thickened milk and [MEDICATION NAME] milk were held at acceptable temperatures of 41 degrees Fahrenheit or less. This had the potential the affect all ten (10) residents who were to receive these beverages. The facility also did not keep records to make sure that cold foods were at appropriate temperatures when received from the food supplier. This had the potential to affect all residents. Facility census: 106. Findings include: a) Five (5) glasses of thickened milk and five (5) glasses of Lactacid milk were on a tray sitting on the counter during observation of the evening meal at 5:00 p.m. on 02/09/09. Temperatures taken of sampled glasses found the beverages were held at 42.9 and 43 degrees Fahrenheit. An interview with the dietary manager, after this observation, found the milks were on a tray with ice packs under it, but this method did not ensure the milk was being held at a cool enough temperature. b) During the dietary observation on 02/09/09 at 5:00 p.m., the dietary manager indicated that, when food was received from the food supplier, temperatures were taken but were not recorded in order to ensure that foods were kept at proper temperatures. .",2014-06-01
11325,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,441,D,0,1,IH3P11,"Based on observation, it was determined the infection control program failed to ensure staff practices were consistent with appropriate infection control techniques. A nurse donned gloves, then contaminated the gloves prior to dressing the resident's wound. One (1) of nineteen (19) current residents on the sample was affected. Resident identifier: #45. Facility census: 106. Findings include: a) Resident #45 On the mid-morning of 02/11/09, a nurse (Employee #112) was observed providing treatment to an unstageable wound on the resident's left heel. The wound was covered with eschar that had loosened from the healthy skin surrounding the wound. After cleaning the wound, the nurse removed her gloves, washed her hands, and donned new gloves. After donning the clean gloves, she opened the packages containing the dressing supplies, then put her hand in her pocket to extract an ink pen. The pen was uncapped, and she used it to label the dressing. The dressing was then applied to the resident's heel wound. The nurse's pocket would be considered an unclean area, as would the pen. This created a potential to introduce nonresident organisms into the resident's wound. .",2014-06-01
11326,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,309,E,0,1,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's dosing instructions, and staff interviews, the facility did not ensure antibiotics were administered at times that would maintain blood levels of the medication for optimal effect. Two (2) of nineteen (19) residents on the sample were identified as being affected, and review of the February medication administration records (MAR) for the 100 hall identified an additional two (2) residents. Resident identifiers: #52, #15, #95, and #51. Facility census: 106. Findings include: a) Resident #15 Review of the resident's medical record found that, on 01/19/09, [MEDICATION NAME] (an antibiotic) had been ordered given three (3) times a day pending the culture of the resident's [MEDICAL CONDITION] site. Review of his MARs revealed the antibiotic had been scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. That meant the three (3) antibiotic doses were given in an approximately nine (9) hour period, leaving fifteen (15) hours between the 5:00 p.m. dose and the 8:00 a.m. dose on the following day. b) Resident #51 The resident's current orders included Bactrim DS to be given twice a day for five (5) days. The antibiotic was scheduled for administration at 9:00 a.m. and 5:00 p.m. on the MAR. This schedule provided for the doses for one (1) day to be given eight (8) hours apart, and the next dose would not be given for approximately sixteen (16) hours. c) Resident #52 The resident's current MAR indicated [REDACTED]. The antibiotic was scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. d) Resident #95 A current order for Bactrim DS to be given twice a day for ten (10) days was noted on the resident's current MAR. The medication was scheduled to be given at 8:00 a.m. and 5:00 p.m. e) The director of nursing was interviewed on 02/11/09. When asked about the scheduling of antibiotics, she was unable to offer a reason for the current schedules. During a discussion regarding maintaining serum levels of certain drugs, especially antibiotics, she acknowledged it would be important to maintain the levels. f) Review of package inserts (obtained for in the Food and Drug Administration's website) from the pharmaceutical companies for each of these antibiotics found that, under the section for ""Dosage and Administration"", each included instructions that doses should be administered every twelve (12) hours if the medication was given twice a day and every eight (8) hours if given three (3) times a day. .",2014-06-01
11327,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,279,E,0,1,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, observations, and staff interviews, the facility did not develop a care plan for each resident which was based on the comprehensive assessment and included measurable goals. For example, residents were assessed as being on scheduled toileting plans, yet their care plans did not include a plan for incontinence management. Goals were not stated in measurable terms, so that progress toward the goal or a need to alter the approaches to the problem could be determined. Additionally, in some instances, the interventions did not lend to achievement of the stated goal. Resident identifiers: #82, #30, #80, and #15. Facility census: 106. Findings include: a) Resident #82 1. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/01/08, revealed she had both short-term and long-term memory problems. She had been assessed as having severe impairment in the area of decision-making; as being understood sometimes; and as rarely being able to understand what was said to her. Her [DIAGNOSES REDACTED]. She was able to move about in her wheelchair independently. Observations of the resident, on 02/11/09, found she had wandered into a room near her own room at 3:30 p.m., and at 3:45 p.m., she had maneuvered her wheelchair into another room nearby. A nursing assistant (Employee #77) was asked whether the resident often wandered into other residents' rooms and replied that she did. Review of the resident's care plan found no care plan to address the issue of this resident wandering into other residents' rooms. 2. Review of the medical record found a nursing entry on 10/03/08 regarding the resident licking her bedside table. Subsequent nurses' notes also described the resident licking things such as the desk at the nurses' station. On 02/11/09, in mid morning, Employee #112 was asked whether the resident still licked things. She said the resident continued to lick things and that the doctor was aware. She also said the resident would usually stop when instructed to do so. Review of the resident's care plan found no plan had been developed to address this behavior. 3. The following goal had been established: ""Will maintain existing ADL (activities of daily living) self performance thru next care plan review."" This goal was not measurable. 4. Another goal was: ""'Res(ident) will remain oriented to self thru next care plan review."" The interventions were to attempt to have her imitate the activity staff wanted her to perform, to attempt to provide consistent routines and caregivers, provide access to a clock and calendar, etc. None of the interventions offered guidance to care givers regarding how the resident was to be ""oriented to self."" 5. Another goal was: ""Ensure needs will be met AEB (as evidenced by) res will be kept clean, dry and well groomed daily thru next care plan review."" The interventions were: ""When talking to resident, use gestures and simple sentences while maintaining eye contact. Monitor for and report any changes in communication abilities / efforts. Provide reassurance and patience when communicating with resident. Gain individual's attention before beginning to converse."" These interventions were related to communication, which did not address the stated goal regarding grooming and hygiene. Additionally, the goal was staff-oriented (what staff would do for the resident), not resident-oriented (what the resident would do for herself). b) Resident #30 1. The goal was: ""Resident will show less frequent experiences of sundown type of anxiouness (sic) by next care plan review."" This goal included no parameters by which a determination of ""less frequent"" could be made. 2. Another goal was: ""Will maintain existing ADL self performance. Resident will be clean well groomed and dressed daily thru next care plan review."" There were no parameters included in this part of the care plan to render it measurable. 3. Another goal was: ""Will be oriented to self thru next care plan review."" The interventions associated with this goal did not provide insight as to how the resident would be oriented to self. 4. Another goal was: ""Ensure needs will be met by staff AEB (as evidenced by) resident will be clean, well groomed and dressed daily thru next care plan review."" The interventions were: ""When talking to resident, use gestures and simple sentences while maintaining eye contact. Monitor for and report any changes in communication abilities/efforts. Provide reassurance and patience when communicating with resident."" The interventions were related to communication, which did not address the stated goal regarding grooming and hygiene. Additionally, the goal was not resident-oriented. 5. Another goal was: ""To show minimal/no side effects of medications thru next care plan review."" The problem statement include the resident was on an antipsychotic medication, but the medications was not identified anywhere in this plan. The interventions were: ""Monitor for and report to physician signs of adverse reaction such as .... Review medication regimen. Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs. Monitor mood state/ behavior. AIMS (abnormal involuntary movement scale) testing q (every) 6 months & prn (as needed). [MEDICAL CONDITION] drug gradual dose reduction if not clinically contraindicated."" None of the interventions would prevent side effects of medications. 6. According to the resident's most recent quarterly MDS, with an ARD of 01/09/09, the resident was able to feed herself with supervision. She was also noted to have chewing and swallowing problems. These factors had not been incorporated in the resident's care plan. 7. The resident's quarterly assessment also indicated she had been assessed as continent of bowel and frequently incontinent of bladder. She was coded as being on a scheduled toileting plan, however, the care plan did not include anything regarding incontinence management. c) Resident #80 1. A goal was: ""Will improve ADL self performance as evidenced by (sic) thru next care plan review."" There was nothing included in the goal to identify how improvement would be evidenced. The goal was not measurable. According to the quarterly MDS, with an ARD of 01/02/09, the resident required limited to extensive assistance with most ADLs. 2. Another goal was: ""Demonstrate understanding by completing task when requested thru next care plan review."" No frequency of the expectation of occurrence was included. The problem statement associated with this goal was: ""Difficulty communicating as evidenced by expressive / communication impairment related to multi-infarct dementia."" According to her quarterly MDS, she usually understood what was said to her and she could usually be understood. Therefore, there was an inconsistency between the assessment and this care plan. 3. Another problem was: ""Dental or oral cavity health problem as evidenced by res with carious, broken, missing teeth."" The goal was: ""will (sic) be able to chew food sufficiently to swallow safely / without pain thru next care plan review."" The interventions were: ""Assist with oral hygiene as needed. Monitor for and report any changes in oral cavity, chewing ability, S&S (signs and symptoms) oral pain, etc."" The plan did not address how the resident was to be enabled to chew food sufficiently in order to swallow safely / without pain. 4. The resident's assessment of 01/02/09, identified the resident as requiring the extensive assistance of one (1) for toileting. She was noted to be occasionally incontinent of bladder and usually continent of bowel and to be on a scheduled toileting plan. Incontinence management was not addressed in the resident's care plan. d) Resident #15 1. A goal was: ""Res. will not have any complications r/t (related to)[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) by next care plan review."" The interventions were: ""Monitor effectiveness of medication taken. Administer med per MD order. Notify MD prn."" Although the goal was stated in preventative terms, the interventions, other than administration of medications, were not preventative in nature. Additionally, no nursing interventions were described in the plan. 2. A goal was established for the resident to show improvement in his balance, range of motion, mobility, ability to transfer, sitting tolerance, and shaping of his stump. The goal did not include any parameters so that progress, or lack of progress, toward the goal could be determined. 3. A problem statement was: ""Decreased safety and I (independence) with self-care ADL's (sic)"" with a goal of ""Maximize safety and I with self-care ADL's"". The only intervention was: ""there ex, there act, ADL (therapeutic exercise, therapeutic activity, activities of daily living)."" This plan offered little insight into the resident's needs. Additionally, it was not stated in measurable terms. .",2014-06-01
11328,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-02-03,203,D,1,0,F0ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of closed medical records [REDACTED]. Four (4) of four (4) residents whose closed records were reviewed did not have evidence of this notice being issued. Resident identifiers: Residents #139, #140, #141, and #142. Facility census: 138. Findings include: a) Residents #139, #140, #141, and #142 Review of the closed medical records [REDACTED]. On the afternoon of 02/03/11, Employee #40, a registered nurse (RN) who worked on the second floor, was asked where the information regarding transfers and discharges would be located. He said there should be a copy in the residents' medical records. He provided copies of forms that had been completed at the time of transfer / discharge which contained the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident was being transferred or discharged . He said these forms were sent with each resident. Upon further description of the information being sought, the employee said they also sent a multi part form with the residents. He went to a desk drawer, but no forms were in the file folder. In late afternoon on 02/03/11, the assistant director of nursing was asked where evidence of the information having been given to the resident / responsible party might be found. She said it should be in the residents' medical records. She looked in the four (4) residents' records and was unable to locate the information for each resident's most recent transfer / discharge. Review of Resident #141's medical record found bed hold notices and appeals notices had been issued on 02/02/10, 03/02/10, 03/05/10, 03/13/10, 05/07/10, and 11/20/10, but one was not found for his 01/04/11 discharge. .",2014-06-01
11329,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-02-03,205,D,1,0,F0ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of closed medical records [REDACTED]'s bed-hold policy. Four (4) of four (4) residents whose closed records were reviewed did not have evidence of this notice being issued. Resident identifiers: #139, #140, #141, and #142. Facility census: 138. Findings include: a) Residents #139, #140, #141, and #142 Review of the closed medical records [REDACTED]. On the afternoon of 02/03/11, Employee #40, a registered nurse who worked on the second floor, was asked where the information regarding transfers and discharges would be located. He said there should be a copy in the residents' medical records. He provided copies of forms that had been completed at the time of transfer / discharge which contained the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident was being transferred or discharged . He said these forms were sent with the residents. Upon further description of the information being sought, he provided a copy of the facility's bed-hold policy. He stated there should be a copy in each resident's medical records. In late afternoon on 02/03/11, the assistant director of nursing was asked where evidence of the information regarding the bed-hold policy having been given to the resident / responsible party might be found. She said it should be in the residents' medical records. She looked in the four (4) records and was unable to locate the information for each resident's most recent transfer / discharge. Review of Resident #141's medical record found bed hold notices had been issued (and signed by a family member) on 02/02/10, 03/02/10, 03/05/10, 03/13/10, 05/07/10, and 11/20/10, but one was not found for his 01/04/11 discharge.",2014-06-01
11330,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2009-06-18,360,D,0,1,1MWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the list of resident diets provided by the facility, and facility staff interview, the facility failed to assure one (1) of four (4) sampled residents received food that met the individual's special dietary needs. Resident identifier: #3. Facility census: 8. Findings include: a) Resident #3 Medical record review found Resident #3 was admitted to the facility on [DATE] for rehabilitation following a [MEDICAL CONDITION]. Further review found the treating physician prescribed a cardiac diet for Resident #3 due to multiple health problems. A nutritional follow-up note, written on 06/09/09, recommended to continue the cardiac diet. Review of the list of resident diets provided by the facility found the resident was documented as receiving a regular diet. A call to the dietary department, placed by Employee #3 during an interview conducted at 3:00 p.m. on 06/06/09, confirmed Resident #3 was receiving a regular diet. Employee #3 verified the diet had been entered incorrectly when the resident returned from having a skin graft. .",2014-06-01
11331,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2009-06-18,371,F,0,1,1MWP11,"Based on observation and facility staff interview, the facility failed to assure the dietary department, which stores, prepares, distributes, and serves food, was maintained in a sanitary condition. This deficient practice had the potential to all residents of the skilled nursing unit. Facility census: 8. Findings include: a) Observations of the dietary department, conducted beginning at 11:40 a.m. on 06/16/09, found the following unsanitary conditions: 1. In the corner on the floor of the dry goods storage area were packages of peanut butter and other food items attractive to mice and insects. 2. An inspection of the dietary walk-in freezer found staff utilized the floor beneath the shelving around the walls to store approximately twenty-six (26) cases of various foods. It was also noted the floor beneath the storage rack located in the center of the freezer was strewn with opened and unopened packages of vegetable and meat products, allowing both to spill out onto the floor. 3. An inspection of the three-compartment sink found no sanitizer in the sink allocated for its use. An interview with the dietary manager revealed the dispensing device was malfunctioning. 4. The wells and surrounding areas of the gas stove burners were noted to be packed with blackened, greasy debris and blackened, unidentifiable chunks of food items. Also, the drip pan was coated with hardened, greasy debris. 5. The knobs on the combination gas stove / grill were noted to be coated with a brown, gummy substance. 6. The handle of the tilt skillet was utilized to store approximately fifteen (15) sets of tongs. An inspection of the backs of the tongs found they were heavily soiled. An interview with a dietary staff member revealed the tongs were stored there and ready for use. 7. The backsplash to the combination gas stove / grill was noted to be heavily soiled with a greasy substance. 8. A member of the dietary staff was noted to be assisting with the noon meal service. This staff member was not wearing an effective hair restraint; the hair net she was utilizing did not cover her bangs or back of her hair.",2014-06-01
11156,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-03-07,241,E,1,0,VSB111,". Based on random observation and staff interview, the facility failed to promote care for residents in a manner that enhanced dignity. Resident #12 was observed eating lunch in the first floor dining room seated in a low wheelchair, and the table was too high to allow the resident easy access to food and drinks. Four (4) female residents (#152, #16, #169, and #44) were observed in a public area of the facility with unkempt hair. Multiple residents (#88, #73, #164, #42, #65, and #6) seated at tables together were not served their meals at the same time in the Park Way dining room at the noon meal on 03/07/11. These practices had the potential to affect more than an isolated number of residents who eat their meals in the facility dining rooms. Resident identifiers: #12, #152, #16, #169, #44, #42, #65, #6, #88, #73, and #164. Facility census: 173. Findings include: a) Resident #12 Observations made in the first floor dining room, on 03/07/11 at 1:30 p.m., found Resident #12 sitting in a low wheelchair. The table was too high for the resident to easily access her food and drinks. While attempting to pick up a glass of tea from the table top, she spilled it in her lap. The facility's administrator and director of nursing (DON) were informed of this observation during an interview at approximately 5:00 p.m. on 03/07/11. -- b) Residents #152, #16, #169, and #44 Observations made in the first floor dining room, on 03/07/11 at 1:30 p.m., found four (4) female residents (Residents #152, #16, #169, and #44) with hair that had not been combed and styled. The administrator and DON were informed of these observations during an interview at approximately 5:00 p.m. on 03/07/11. -- c) Residents #88, #73, #164, #42, #65, and #6 Observation of the noon meal, in Parkway Dining Area on 03/07/11 beginning at 12:15 p.m., found Residents #88, #73, and #164 seated together at a table. Resident #88 was served her meal while Residents #73 and #164 waited for approximately twenty (20) minutes for their trays to be delivered to them. In the same dining area, Residents #42, #65, and #6 were seated together at a table. Resident #65 received her meal while Residents #6 and #42 waited for their meals. Residents seated at other tables in the dining room were served meals before Employee #150 returned with Resident #6's meal. Resident #42 continued to wait for her tray for approximately eight (8) minutes while other residents were served. Two (2) staff members (Employees #185 and #150) were in the dining room for the meal. Employee #150 stated she tried to serve all residents at the same table before serving residents at another table but was unable to do so, stating, ""It depends on how the trays come out from the kitchen.""",2014-07-01
11157,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-03-07,225,D,1,0,VSB111,". Based on record review and staff interview, the facility failed to report allegations of neglect to all State officials as required. This was true four (4) of fifteen (15) concern forms (reviewed from 01/01/11 through 03/07/11) involving four (4) different residents. Resident identifiers: #177, #97, #108, and #51. Facility census: 173. Findings include: a) Resident #177 Review of the facility's concern forms, on 03/07/11, revealed a concern dated 02/15/11 from Resident #177's daughter, which stated (verbatim), ""Residents daughter came to my office wanting to express some concern over her mothers care. Reports when (Resident #177's name) went to the hospital and had to have her undergarment removed for treatment her mother had a foul odor coming from her peri area. The daughter reports that both (Resident #177's name) and her were embarrassed by her presentation. The daughter was visibly upset during this meeting. ..."" Further review of the concern form described the following action taken by the facility: ""An in-service was given when the residents daughter first expressed a concern with call lights. Showers are changed to during the day. Will speak with MD regarding the order for cream to abd (abdominal) folds."" There was no evidence to reflect this allegation of neglect was immediately reported to State officials as required. -- b) Resident #97 Review of the facility concern forms, on 03/07/11, revealed a concern dated 02/15/11 from Resident #97, which stated (verbatim), ""Res. (resident) states the only CNA (certified nursing assistant) who gives her a bath / shower is (name of CNA). Res. (resident) states if (name of CNA) is not here she doesn't get her bath."" Further review revealed the facility had taken the following action: ""In service to CNA staff. Staff will have the shower schedule in my office and will have to escort the resident to shower with me or staff nurse witness to shower..."" There was no evidence to reflect this allegation of neglect was immediately reported to State officials as required. -- c) Resident #108 Review of the facility concern forms, on 03/07/11, revealed a concern dated 02/15/11 from Resident #108, which stated (verbatim): ""Res. states she does not get her bed baths or showers. States no one ever even offers."" Further review revealed the facility had taken the following action: ""In service to CNA staff. Staff will have the shower schedule in my office and will have to escort the resident to shower with me or staff nurse witness to shower..."" There was no evidence to reflect this allegation of neglect was immediately reported to State officials as required. -- d) Resident #51 Review of the facility concern forms, on 03/07/11, revealed a concern dated 02/15/11 from Resident #51, which stated (verbatim): ""Res. states she doesn't get showers offered to her twice a week and doesn't get a sponge bath, hardly ever."" Further review revealed the facility had taken the following action: ""In service to CNA staff. Staff will have the shower schedule in my office and will have to escort the resident to shower with me or staff nurse witness to shower..."" There was no evidence to reflect this allegation of neglect was immediately reported to State officials as required. -- e) The facility's administrator and assistant director of nursing, when interviewed on 03/07/11 at approximately 4:30 p.m., verified the above allegations had not been reported to State officials. .",2014-07-01
11158,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-03-10,309,G,1,0,LH7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility protocol, staff interview, physician interview, and review of information published by the American Diabetic Association, the facility failed to provide clear and precise instructions to nursing staff concerning when to notify the physician of elevated blood glucose levels for residents with diabetes. This deficient practice resulted in repeated untreated episodes of [MEDICAL CONDITION] for two (2) of four (4) sampled residents, with one (1) of these residents requiring hospitalization . Residents #65 and #49 were both ordered Accu-checks four-times-a-day (qid); prior to meals and at bedtime. Both residents displayed pre-meal blood glucose levels greater than 200 mg/dl on multiple occasions with no evidence of physician notification. Resident #65's [MEDICATION NAME] was discontinued shortly after her admission in response to the pharmacist's recommendation. This antiglycemic medication was not replaced with an alternate form of treatment. The resident suffered harm when her blood glucose level reached 512 mg/dl and she required hospitalization . This resident's blood glucose level was recorded to be greater than 300 mg/dl on three (3) occasions immediately prior to her hospitalization . The facility could provide no evidence that clear and precise instructions were provided to nursing staff members to ensure the physician was notified of these increased blood glucose levels. Resident #49 experienced multiple episodes of [MEDICAL CONDITION] prior to the physician being notified. Resident identifiers: #65 and #49. Facility census: 64. Findings include: a) Resident #65 Resident #65 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her medical record found her admission physician orders [REDACTED]. She was also ordered Accu-checks qid to be administered prior to meals and at bedtime. Review of her documented glucose levels found she was admitted with a blood glucose of 118 mg/dl. Review of the medication regimen review, dated 01/19/11, found the pharmacist recommended the resident's [MEDICATION NAME] be discontinued due to laboratory results indicating decreased renal function. He further recommended adding [MEDICATION NAME] if needed. The recommendation was agreed to by the physician, and her [MEDICATION NAME] was discontinued on 01/21/11. The physician did not order [MEDICATION NAME] or any other antiglycemic medication. The medical record contained no orders, parameters, or instructions to nursing staff members to inform the physician of hyperglycemic episodes. Review of the American Diabetic Association 2011 guidelines found [MEDICAL CONDITION] was defined as a blood glucose level great than or equal to 200 mg/dl at any time. Further review of the diabetic monitoring documentation found the resident's blood glucose was recorded as follows: - 291 mg/dl at 11:45 a.m. on 01/29/11, - 285 mg/dl at 8:00 p.m. on 01/29/11, - 308 mg/dl at 11:45 a.m. on 01/30/11, - 324 mg/dl at 8:45 p.m. on 01/30/11, - 265 mg/dl at 6:45 a.m. on 01/31/11, and - 361 mg/dl at 4:45 p.m. on 01/31/11. The facility could provide no evidence that staff notified the physician concerning these hyperglycemic episodes. A nursing note, at 9:05 a.m. on 01/31/11, documented the resident's blood glucose reading to be 512 mg/dl. The resident was transported to the hospital where she was determined to be suffering from a urinary tract infection. She was returned to the facility with orders for insulin injections of [MEDICATION NAME] 5 mg to be administered at bedtime. In an interview on 03/09/11 at 1:00 p.m., the resident's physician agreed the facility did not have procedures in place to contact him when a resident's blood glucose level reached defined parameters. He stated a protocol would be developed for nursing staff to follow. -- b) Resident #49 Review of the medical record found this resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the diabetic monitoring record found the resident's blood glucose levels were greater than 200 mg/dl on 02/10/11, 02/11/11, 02/12/11, 02/13/11, and reached 296 mg/dl at 11:45 a.m. on 02/14/11. The physician was not notified of these episodes of [MEDICAL CONDITION] until 02/15/11. He ordered the resident's [MEDICATION NAME] to be increased to 10 mg bid on 02/15/11. Review of the resident's blood glucose levels following the increase in medication noted documentation of [MEDICAL CONDITION] with levels above 200 mg/dl on a daily basis from 02/15/11 until the physician was notified on 03/01/11. The resident's blood glucose was documented to be: - 315 mg/dl on 02/19/11 at 11:45 a.m., - 305 mg/dl on 02/19/11 at 4:45 p.m., - 322 mg/dl on the morning of 02/24/11, and - 398 mg/dl on 02/25/11 at 4:45 p.m. After notification on 03/01/11, the physician ordered Actos 15 mg to be added to her medication regimen. In an interview on 03/07/11 at 2:00 p.m., a registered nurse (RN - Employee #84) confirmed that nursing staff members were provided no orders or parameters instructing nursing staff to contact the physician for episodes of [MEDICAL CONDITION].",2014-07-01
11159,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-03-30,356,C,1,0,JH3J11,". Based on observation and staff interview, the facility failed to post nurse staffing data on a daily basis at the beginning of each shift, as required. This practice has the potential to affect all residents and public desiring to access to this information. Facility census: 94. Findings include: a) On the morning of 03/28/11 at 8:00 a.m., the surveyor was checking for nurse staffing information that is to be posted. When questioned, the executive director (ED) escorted the surveyor to a signboard close to the entry of the East side hallway, stating this was where that information was to be located. The signboard was empty / blank of any information. The ED then proceeded to ask the nurse who was passing medications on East side (Employee #66) where the staffing information was. The nurse replied that she usually posted the information after she gets through with her medication pass. The ED asked the nurse to post it now. It was then posted at 8:08 a.m. Again on the morning of 03/30/11, the nurse staffing information had not been posted on the designated board as of 8:30 a.m. when the shift begins at 7:00 a.m. The regulation states the information regarding nurse staffing is to be posted at the beginning of each shift. .",2014-07-01
11160,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-03-30,441,E,1,0,JH3J11,". Based on observation and staff interview, the facility failed to 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. Staff permitted unauthorized individuals to enter the locked East side nourishment center, which was labeled ""Staff Only"", and staff permitted residents free access to the clean linen storage area These practices have the potential to affect all residents residing on the East wing of the facility with a census of forty-seven (47) residents. Facility census: 94. Findings include: a) Observation found facility staff allowed residents and family members to enter the nourishment pantry on the East wing of the facility on their own at any time. The door to the East wing nourishment room (pantry) was labeled with a sign stating ""Staff Only"", and the door was equipped with a key pad locking device into which staff entered a number to gain access to the room. The door was shut but was not locked when the surveyor observed Resident #7 entering the room. When interviewed regarding this practice at 8:20 a.m. on 03/28/11, Employees #48 and #4 (a registered nurse and licensed practical nurse, respectively) stated the residents observed were alert / oriented and used to helping themselves. b) At 8:25 a.m. on 03/28/11, a female resident (#51) was observed entering the clean linen closet and helping herself to towels and other items in preparation for a bath. The linen room door had no sign and was not completely shut when the female resident entered to get supplies. c) On 3/28/11 at 10:00 a.m., the family member of Resident #28 was observed entering the pantry, caring beverages. The family member was observed being able to enter the pantry without entering a code on the key pad. Employee #70 (a registered nurse) was standing outside the pantry in the hallway on 03/28/11 at 10:00 a.m. This employee was questioned about the practice of a family member entering the pantry designated for access by staff only. At this time, she shut and locked the pantry door. d) The executive director (ED - Employee #13) and the director of nursing (DON - Employee #64), when interviewed on the afternoon of 03/28/11, stated the items in the pantry were individually wrapped and that access to this area by alert residents should not create a problem. e) On 03/29/11 at 3:05 p.m., observation again found the East wing pantry door not locked and easy to access without entering a code by any individual. This practice would not prevent wandering residents (who may notice alert residents going into this location and getting items on their own) from helping themselves, nor can facility staff ensure these residents would use proper hand washing techniques when in these areas.",2014-07-01
11161,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-03-30,323,D,1,0,JH3J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and observation, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents for two (2) of eleven (11) sampled residents. The interdisciplinary team assessed Resident #73 as being at risk for falls and as requiring a pressure sensitive alarm to her bed and chair. Observation of Resident #73, while she was in bed on the morning of 03/30/11, found no pressure sensitive alarm in place. Resident #95 was admitted to the facility on [DATE] with a history of falling. On 01/02/11, he fell when trying to take himself to the bathroom, and on 01/03/11, he lost his balance while sitting on the bed and fell to the floor. Following the fall on 01/02/11, the interdisciplinary team recommended Resident #95 be evaluated for a toileting program; a 3-day voiding diary, as a prerequisite to the toileting program, was not initiated until 01/06/11; after the voiding diary was completed on 01/08/11, the physician did not order the initiation of a toileting program until 01/12/11. Following the fall on 01/03/11, the physician ordered the use of landing strips on the floor at bedside on 01/04/11; however, no landing strips were not available for use until 01/07/11. Resident identifiers: #73 and #95. Facility census: 94. Findings include: a) Resident #73 Medical record review revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #73 had fallen on three (3) occasions since 07/27/10. Additional falls occurred on 09/30/10 and 01/27/11. After the 01/27/11, fall the facility completed a ""Verification of Investigation"" form, which documented the facility would add the use of a ""Pressure sensitive alarm to chair and bed."" Observation, on the morning of 03/30/11, found Resident #73 in her room with no pressure sensitive alarm on her bed. On 03/30/11 at 9:15 a.m., the facility's assessment coordinator (Employee #22) verified the alarm was not on the resident's bed. Employee #22 retrieved a Tabs alarm, which had been lying on the resident's night stand, and placed it on the resident's bed. In an interview on the morning of 03/30/11, Employee #64 (the director of nursing - DON) verified the pressure sensitive alarm was ordered on [DATE], as an intervention to prevent falls for Resident #73. -- b) Resident #95 Medical record review revealed an [AGE] year old male admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The resident's minimum data set assessment (MDS), with an assessment reference date of 01/10/11, documented the resident had fallen in the last month prior to admission and had also fallen in the last two (2) to six (6) months prior to admission. - On 01/02/11 at 2:45 p.m., Resident #95 was attempting to ambulate to the bathroom unassisted and fell . According to the facility's ""Verification of Investigation"" form dated 01/02/11, the resident was to be ""... assessed by therapy and evaluated for a toileting program"". - On 01/03/11 at 3:15 p.m., the resident lost his balance while setting on the bed and fell on to the floor. - On 01/04/11, the physician ordered landing strips beside bed. - Documentation completed by the nursing assistants related to the use of landing strips, which started on the night shift of 01/04/11 and continued through the evening shift of 01/07/11, revealed (copied verbatim): ""There is no landing strips in room."" - On 01/06/11, staff began an evaluation of Resident #95 for a toileting program, by initiating a voiding diary. The voiding diary completed on the following dates: 01/06/11, 01/07/11, and 01/08/11. - No action was taken in response to the completion of the voiding diary until four (4) days later (on 01/12/11), when the physician wrote an order for [REDACTED]. The delay in initiation of Resident #95's toileting program, as well as the absence of the landing strips for a period of three (3) days after the order for their use were written, were discussed with the DON on the afternoon of 03/29/11. These concerns were discussed again with the DON at approximately 10:00 a.m. on 03/30/11. The DON was unable to provide evidence the landing strips were present when ordered. She stated the toileting program took time to initiate, because the facility had to complete a voiding diary for three (3) days (although the recommendation for a toileting program was made on 01/02/11 and the voiding diary had been completed on 01/08/11). Measures to promote Resident #95's safety related to falls were identified but not implemented in a timely manner. .",2014-07-01
11162,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-03-30,514,D,1,0,JH3J11,". Based on medical record review, staff interview, and review of the American Health Information Management Association (AHIMA) Long Term Care Health Information Practice and Documentation Guidelines, the facility failed to adhere to professional standards and practices by failing to note the effective dates of changes made to residents' care plans. This was true for two (2) of eleven (11) sampled records. Resident identifiers: #3 and #95. Facility census: 94. Findings include: a) Resident #3 Review of Resident #3's, care plan dated 03/10/11, revealed the following problem statement: ""At risk of injury r/t (related to) falls, poor safety awareness, hx. (history) of falls."" Three (3) interventions related to this problem included: 1. ""Nonskid strips to floor."" 2. ""Tabs (type of mobiltiy alarm system) to w/c (wheelchair) when up."" 3. ""He can ambulate to BR (bathroom) /c (with) walker."" The above interventions were not dated to indicate when they were added to the resident's care plan. The assessment coordinator (Employee #22) was interviewed regarding this concern on the morning of 03/30/11. No further information was provided. -- b) Resident #95 Review of the Resident #95's care plan revealed two (2) separate care plans addressing the same problem: ""At risk for falls..."" The first care plan was initiated on 01/01/11, the second care plan was initiated on 01/14/11. There were thirteen (13) interventions documented on the 01/14/11 care plan addressing the prevention of falls. The dates of implementation for the thirteen (13) interventions were not documented. -- c) The AHIMA documentation guidelines for long term care state: ""Every entry in the medical record must include a complete date..."" (Section 5.2.3). The care plan is part of each resident's medical record. Further standards of professional practice established by AHIMA state: ""Federal regulation for nursing facilities and skilled nursing facilities require organizations to maintain their clinical records in accordance with accepted professional standards and practices and to employ or contract with professional necessary to carry out the regulations."" .",2014-07-01
11163,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-03-02,282,D,1,0,VRUU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure staff provided therapeutic care and services ordered by the physician for one (1) of fifteen (15) sampled residents. Resident identifier: #6. Facility census: 116. Findings include: a) Resident #6 A review of the medical records of Resident #6 revealed this [AGE] year old male was admitted to the facility on [DATE] after the surgical repair of a [MEDICAL CONDITION]; his [DIAGNOSES REDACTED]. During his hospitalization , a urologist inserted an indwelling urinary catheter and recommended that it be continued. The catheter was ordered to be continued at admission by the attending physician at the facility. The resident was discharged home on[DATE], by a registered nurse. The nurse removed the indwelling urinary catheter immediately prior to discharge. However, there was no physician's order to remove the catheter, and the discharge instructions did not include any education regarding aftercare for catheter removal. A review of hospital records revealed the resident was readmitted there on 01/23/11, after having been unable to void for 24 hours. The resident was readmitted to the facility on [DATE], with the catheter back in place. During an interview with the director of nursing at 3:25 p.m. on 03/01/11, she acknowledged the action (removal of the urinary catheter without a physician's order) had been discovered when the resident was readmitted and had been investigated, resulting in the issuance of an ""Employee Warning Notice"" to the responsible nurse on 02/10/11. The nurse admitted removing the catheter upon insistence by the resident's wife, although she knew it was against policy. .",2014-07-01
11164,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-03-02,285,D,1,0,VRUU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure applicants for admission were assessed for the need for specialized services for mental illness and/or mental [MEDICAL CONDITION] as required by law prior to admission to the facility for two (2) of fifteen (15) sampled residents. Resident identifiers: #6 and #79. Facility census: 116. Findings include: a) Resident #6 A review of the medical record revealed Resident # 6 was initially admitted to the facility on [DATE]. However, the facility did not receive feedback on the need for a Level II evaluation until 12/06/10, as recorded on the pre-admission screening and resident review document titled PAS-2000. (Level II evaluations are to be completed, when a determination is made to do so by an outside agency, prior to an applicant's admission to a nursing home, in order to identify the need for specialized services to treat mental illness and/or mental [MEDICAL CONDITION].) The resident was discharged on [DATE], and readmitted on [DATE]. Again, the facility did not receive feedback on the need for a Level II evaluation for this admission until 02/03/11, as recorded on the PAS-2000. -- b) Resident #79 A review of the medical record revealed Resident #79 was initially admitted to the facility on [DATE]. However, the facility did not receive feedback on the need for a Level II evaluation until 12/02/10, as recorded on the PAS-2000. -- c) During an interview with the director of nursing (DON) at 3:25 p.m. on 03/01/11, she acknowledged both residents were admitted into the facility prior to receiving feedback on the need for Level II evaluations. .",2014-07-01
11165,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-03-02,514,D,1,0,VRUU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure an accurate and complete medical record for one (1) of fifteen (15) sampled residents. Resident #6 was discharged home on[DATE], by a registered nurse. The nurse removed the indwelling catheter immediately prior to discharge. There was no physician's order for the removal of the catheter. Additionally, review of the nursing notes found no documentation regarding the removal of the urinary catheter, issuance of discharge instructions to the resident / family regarding aftercare and precautions, and/or notification to the physician of having performed this procedure. Resident identifier: #6. Facility census: 116. Findings include: a) Resident #6 A review of the medical records of Resident #6 revealed this [AGE] year old male was admitted to the facility on [DATE] after the surgical repair of a [MEDICAL CONDITION]; his [DIAGNOSES REDACTED]. During his hospitalization , a urologist inserted an indwelling urinary catheter and recommended that it be continued. The catheter was ordered to be continued at admission by the attending physician at the facility. The resident was discharged home on[DATE], by a registered nurse. The nurse removed the indwelling catheter immediately prior to discharge. There was no physician's order for the removal of the catheter. A review of the nursing notes found no documentation regarding the removal of the urinary catheter, discharge instructions issued to the resident / family regarding aftercare and precautions associated with removal of the catheter, and/or notification to the physician of having performed this procedure. During an interview with the director of nursing at 3:25 p.m. on 03/01/11, she acknowledged the action (removal of the urinary catheter without a physician's order) had been discovered when the resident was readmitted and had been investigated, resulting in the issuance of an ""Employee Warning Notice"" to the responsible nurse on 02/10/11. She also agreed the incident had not been documented. .",2014-07-01
11166,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2011-03-03,463,E,1,0,3LVK11,". Based on performance testing and staff interview, the facility failed to maintain all portions of the nurse call system operable as designed / required. This deficient practice affected seventeen (17) of forty (40) resident rooms and toilet rooms. Facility census: 55. Findings include: a) During tour of the facility on 02/28/11 at approximately 11:30 a.m., the nurse call system failed to operate as designed / required, when tested , in seventeen (17) of forty (40) resident rooms and toilet rooms. The rooms were identified as B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, B14, and B15. Also, at approximately 12:15 p.m. on this same date, the nurse call system at the bed was not operable in rooms A12 and A20, when tested . b) During tour of the facility on 02/28/11 at approximately 11:30 a.m., cow bells were observed at the resident beds in fifteen (15) of fifteen (15) resident rooms and ten (10) of fifteen (15) toilet rooms on the ""B"" floor. A cow bell was not observed to be available for use in the toilet rooms for B1, B3, B9, B10, and B12. c) On 03/01/11 at approximately 3:45 p.m., an interview with the administrator revealed that, due to the failure of the nurse call system on the entire ""B"" floor, the facility purchased cow bells on 11/12/10 for the ""B"" floor residents to use. This interview also revealed that, as of this date (03/01/11), there was no specific date set to start installation of a new nurse call system. Also, there was no documentation evidence available to indicate that a set of plans for the new nurse call system had been submitted to the Office of Health Facility Licensure and Certification for review and approval.",2014-07-01
11167,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2011-03-03,246,E,1,0,3LVK11,". Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual resident needs for twelve (12) of nineteen (19) sampled residents, by failing to provide a means by which they may summon staff for assistance in the absence of a fully functional nurse call system. Resident identifiers: #25, #17, #30, #10, #6, #12, #15, #18, #28, #36, #41, and #42. Facility census: 55. Findings include: a) During tour of the facility on 02/28/11 at approximately 11:30 a.m., the nurse call system failed to operate as designed / required, when tested , in seventeen (17) of forty (40) resident rooms and toilet rooms. (See also citation at F463.) 1. Resident #25 During tour of the facility on 02/28/11 at 12:00 p.m., observation found Resident #25 did not have a cow bell in her room. The resident said, ""I don't know where it is."" This surveyor stepped outside of the room next to the dining room and could hear Resident #25 hollering that she was thirsty. At 12:05 p.m., a nurse aide (Employee #29) was passing by the room and went to see what the resident wanted. At 2:00 p.m., this surveyor again checked on Resident #25, and she still did not have a cow bell. At 3:40 p.m., this surveyor observed Resident #25 again and she still did not have a cow bell in her room. The above findings were then reported to the unit charge nurse (Employee #42), and this surveyor asked Employee #42 for assistance in locating Resident #25's cow bell. Employee #42 looked and could not find it; she said, ""I will have to get her another one."" - 2. Resident #17 During a random observation on 02/28/11 at 3:35 p.m., Resident #17 was in a geri chair in the middle of her room; her bed was to the left of her, and her cow bell was placed on the bedside table (which was also to the left of her bed). She had no way to reach the cow bell. Her roommate was not in the room at the time. This surveyor asked the resident how she let staff know when she needed assistance. She stated, ""I ring the cow bell when I can reach it."" This finding was reported to the interim director of nursing (DON - Employee #68). - 3. Residents #30 and #10 Residents #30 and #10 occupied rooms located on A floor. During tour of the facility with the administrator (Employee #67) on 02/28/11, the nurse call system at the bedside in these rooms did not function when tested . The administrator stated, ""These may be the ones they worked on last week."" She then confirmed this with another staff member. No cow bells had been provided to these residents. - 4. Residents #6, #12, #15, #18, #28, #36, #41, and #42 Observations, during tour of the facility with the administrator on 02/28/11 at 12:00 p.m., found eight (8) toilet rooms on the B floor without any type of call system (including no cow bells available for use). These toilet rooms were used by Residents #6, #12, #15, #18, #28, #36, #41, and #42. When asked how she would summon staff assistance if needed, Resident #6 stated, ""I just holler when I need help."" On 02/28/11 at 12:15 p.m., the administrator stated, ""There is supposed to be a cow bell in every bathroom."" -- b) On 03/01/11 at 1:30 p.m., the administrator and the maintenance supervisor (Employee #41) were asked how long the nurse call system on B floor had been out of service. Employee #41 could not remember. On 03/01/11 at approximately 3:45 p.m., an interview with the administrator revealed that, due to the failure of the nurse call system on the entire B floor, the facility purchased cow bells on 11/12/10 for the B floor residents to use. .",2014-07-01
11168,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,225,E,1,0,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, review of an agreement between the facility and a temporary staffing agency, review of a newsletter sent by the State survey and certification agency to all licensed nursing homes and Medicare / Medicaid certified nursing facilities in [DATE], and staff interview, the facility failed to ensure three (3) nursing assistants, whose services the facility retained through a temporary staffing agency, received a statewide criminal background check in an effort to uncover any past criminal prosecutions that would indicate they were unfit for duty in a nursing facility. Employee identifiers: #149, #150, and #151. Facility census: 112. Findings include: a) Employees #149, #150, and #151 On [DATE] at 10:00 a.m., review of personnel files found three (3) nursing assistants (Employees #149, #150, and #151) whose services the facility retained through a temporary staffing agency. All three (3) files failed to contain evidence of a statewide criminal background check completed by the West Virginia State Police, in an effort to uncover past criminal convictions that may indicate they were unfit for duty in a nursing facility. Review of the Supplemental Staffing Services Agreement, on page 3, section 1.5, found: ""Agency shall assure that all Personnel meet the following criteria: ... b) Meet State, Federal, Agency and Genesis conditions of employment regarding: Authorization and Release for the Procurement of a Consumer and/or Investigative Report (criminal background check); Police check (as applicable); Nurse Aide Registry; health clearance; TB skin testing; provisions of professional references; CPR certification; proof of negative results of a five (5) panel drug screen; acceptance or declination of [MEDICAL CONDITION] vaccination; documentation of which will be kept in the Agency's personnel file to be presented to the Center or Genesis or to such other party as may be required by law upon request."" This agreement did not require a statewide criminal background check be conducted on personnel whose services would be used by the facility. In a newsletter sent by the State survey and certification agency to all licensed nursing homes and Medicare and/or Medicaid certified nursing facilities in [DATE], the following requirements were communicated with respect to screening of staff: ""... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. ..."" In an interview on [DATE] at 10:15 a.m., the administrator was informed the contracted employees' personnel files did not contain evidence of statewide background checks. No additional information was produced, prior to the survey team exiting the building, to indicate statewide background checks were completed for these individuals. --- Part II -- Based on record review and staff interview, the facility failed to immediately report allegations of resident abuse / neglect to all appropriate agencies in accordance with law for one (1) of twenty (20) sampled residents and one (1) resident of random opportunity. Resident identifiers: #49 and #63. Facility census: 112. Findings include: a) Resident #49 Medical record review, on the afternoon of [DATE], revealed a nursing progress note dated [DATE] at 05:48 a.m., which stated, ""This nurse called to residents room by nurse & CNA (certified nursing assistant) on 200 hall resident upset & yelling after CNA attempted to check resident for urinary incontinence. Res(ident) states he 'thought there was a rukus (sic) the other night & that I (he) may have been violated', (sic) explained to resident that I was on shift the other night & nothing had happened. Resident calmed down & let me check his brief which was dry. Told CNA to make sure she takes another aide or nurse with her when caring for the resident."" The nursing staff failed to report this allegation to the administrator and, subsequently, the facility failed to report the allegation to the State agency and certification agency and/or complete a thorough investigation. On the afternoon of [DATE], the director of nursing (DON), when asked about the above statement from Resident #49, confirmed the ""nurse did not tell anyone, and the allegation was not reported nor investigated."" b) Resident #63 On [DATE], Resident #63 alleged, ""Someone came in and beat me up."" The resident had bruising to both arms. This allegation of physical abuse was not immediately reported to State agencies as required by law. An interview with the DON and administrator, on [DATE] at 11:00 a.m., revealed she felt they were unsure of who had taken care of the resident and that is why the allegation of abuse was not self-reported. On [DATE] at 2:00 p.m., the administrator and the social worker stated the allegation of abuse would be submitted immediately to the appropriate State agencies. .",2014-07-01
11169,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,492,D,1,0,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review and staff interview, the facility failed to ensure three (3) nursing assistants, whose services were retained by the facility through a temporary staffing agency, received copies of the WV Legislative Rule regarding the Nurse Aide Abuse Registry, as required by State law (69CSR,[DATE]). Employee identifiers: #149, #150, and #151. Facility census: 112. Findings include: On [DATE] at 10:00 a.m., review of personnel files found three (3) nursing assistants (Employees #149, #150, and #151) whose services the facility retained through a temporary staffing agency. All three (3) files failed to contain evidence that each nursing assistant was given a copy of the WV Legislative Rule regarding the Nurse Aide Abuse Registry, as required by 69CSR,[DATE]. Review of the Supplemental Staffing Services Agreement, on page 3, section 1.5, found: ""Agency shall assure that all Personnel meet the following criteria: ... b) Meet State, Federal, Agency and Genesis conditions of employment regarding: Authorization and Release for the Procurement of a Consumer and/or Investigative Report (criminal background check); Police check (as applicable); Nurse Aide Registry; health clearance; TB skin testing; provisions of professional references; CPR certification; proof of negative results of a five (5) panel drug screen; acceptance or declination of [MEDICAL CONDITION] vaccination; documentation of which will be kept in the Agency's personnel file to be presented to the Center or Genesis or to such other party as may be required by law upon request."" This agreement did not require each contracted nursing assistant be given a copy of the WV Legislative Rule regarding the Nurse Aide Abuse Registry, as required by State law. On [DATE] at 10:15 a.m., the administrator was informed the contracted employees' personnel files did not contain evidence that these nursing assistants received copies of the Nurse Aide Abuse Registry rule. No additional information was produced.",2014-07-01
11170,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-11-24,203,D,1,0,PYDH11,"Based on record review and staff interview, the facility failed to provide required contact information on a thirty (30) day discharge notice for one (1) of four (4) sampled residents. The thirty (30) day discharge notice the facility provided to the resident's medical power of attorney representative did not include the address and telephone number of the West Virginia State Board of Review, which is the sole State agency with the authority to act upon an appeal of the discharge decision. Resident identifier: #7. Facility census: 110. Findings include: a) Resident #7 Resident #7's medical record, when reviewed on 11/24/09 at 10:30 a.m., disclosed the resident's son was sent a thirty (30) day discharge notice. The social worker (SW- Employee #118), when interviewed on 11/24/09 at 11:30 a.m., disclosed a copy of the thirty (30) day discharge notice was located in the business office. Review of a copy of the discharge notice, when provided by the SW, found the form did not contain the address and telephone number of the West Virginia State Board of Review, the sole State agency with the authority to act upon an appeal of the discharge decision. The medical records clerk (Employee #121), when interviewed on 11/24/09 at 1:30 p.m., acknowledged there were no additional discharge notices available in the resident's medical record that contained the required contact information for the West Virginia State Board of Review. The administrator (Employee #120), when interviewed on 11/24/09 at 11:35 a.m., stated, ""No other thirty (30) day discharge notices have been sent in the past three (3) years."" The administrator acknowledged the discharge notice sent to the resident's medical power of attorney representative did not contain the required address and phone number for the West Virginia State Board of Review.",2014-07-01
11171,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-03-10,225,D,1,0,EGWW11,". Based on record review and staff interview, the facility did not report an allegation of neglect by a nursing assistant, involving one (1) of three (3) sampled residents, to the State Nurse Aide Registry as required. Resident identifier: #67. Facility census: 77. Findings include: a) Resident #67 A review of an immediate fax report, sent by the facility to the Office of Health Facility Licensure and Certification (OHFLAC) Nursing Home Program on 02/09/11, revealed the following allegation (stated verbatim): ""Director of Nursing (name) spoke with family on 02/09/11 in the evening regarding a complaint they voiced during conversation family stated resident was neglected, because when family came to see resident on 02/06/11 they found resident soaked. Family stated resident's brief was soaked, clothes were wet and socks were wet."" The report form indicated the incident of neglect occurred a 1:00 p.m. on 02/06/11. The name of the nursing assistant responsible for rendering care to Resident #67 on the day shift of 02/06/11 was known to the facility; however, there was no evidence the facility reported this allegation of neglect by a nursing assistant to the State Nurse Aide Registry. An interview with the social worker, on 03/10/11 at 2:00 p.m., confirmed the allegation of neglect was reported to OHFLAC's Nursing Home Program but not to the State Nurse Aide Registry. The social worker reported she felt sending the immediate fax to the Nursing Home Program was all she needed to do concerning allegations of neglect. She stated she knew the date and time of the alleged neglect, but she did not realize she needed to send the name of the nursing assistant who was assigned to care for the resident. .",2014-07-01
11172,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-03-10,309,D,1,0,EGWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of three (3) sampled residents received medication in accordance with physician's orders [REDACTED].#33 did not receive [MEDICATION NAME] (an anticoagulant) doses as ordered for four (4) days. Facility census: 77. Findings include: a) Resident #33 Record review revealed a physician's orders [REDACTED]. PT/INR recheck on 12/21/10."" Another physician's orders [REDACTED]."" A review of the facility's ""Medication Error Report"", dated 12/18/10, revealed Resident #33 did not receive [MEDICATION NAME] for four (4) days. The [MEDICATION NAME] order written on 12/15/10 was not transcribed onto the Medication Administration Record [REDACTED] An interview with a licensed practical nurse (LPN - Employee #43), on 03/10/11 at 1:45 p.m., revealed the resident's [MEDICATION NAME] order from 12/15/10 was not transcribed onto the MAR. The resident did not receive the alternating dose of the [MEDICATION NAME] for four (4) days as a result of the transcription error. She further stated, ""I thought I put the [MEDICATION NAME] on the MAR, but I guess I didn't. I told the Director of Nursing that I thought I had written the medication on the MAR, but no one could find the MAR. I probably didn't write it on the MAR."" An interview with the director of nursing (DON - Employee #67), on 03/10/11 at 3:00 p.m., revealed she was working as the assessment coordinator when she was notified that a medication error was made concerning Resident #33 not receiving four (4) days of [MEDICATION NAME]. An LPN had discovered the error and reported the error to the previous DON. A review of the facility's ""Medication Error Review Sheet"", dated 12/28/10, revealed, ""The medication was not transcribed correctly, the right dose was not given and the administration of the medication was not documented correctly. Counseled individually, reviewed importance of accuracy."" A review of the resident's MAR for December 2010 revealed the resident did not receive the [MEDICATION NAME] as ordered (alternating between doses of 6 mg and 8 mg a day) on 12/14/10, 12/15/10, 12/16/10, and 12/17/10. The resident received a new physician's orders [REDACTED]. A review of a lab received on 12/18/10 revealed the resident's [MEDICATION NAME] time (PT) was 12 (normal range is 9.5 to 11.5) and the INR was 1.1 (normal range is 1 to 3.5). Previous labs collected on 12/15/10 revealed the following results: PT was 21.9 and INR was 2.0. On 12/14/10, the resident's PT was 23.8 and INR was 2.2. The PT was elevated on 12/14/10 and 12/15/10, and the INR for both days was within the normal range. .",2014-07-01
11173,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-03-10,315,D,1,0,EGWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not provide timely treatment and services to one (1) of three (3) sampled residents who had a urinary tract infection [MEDICAL CONDITION]. Resident #67 was exhibiting signs and symptoms of a UTI, and on 02/24/11, the physician ordered a urinalysis (UA) and culture and sensitivity (C&S). The facility obtained the UA but failed to obtain the C&S as ordered, which delayed identification and treatment of [REDACTED]. Findings include: a) Resident #67 Medical record review revealed a physician's orders [REDACTED]."" A review of the resident's labs collected on 02/24/11 revealed the UA was completed, but no C&S had been requested for the resident. The urinalysis indicated abnormal findings with color amber, clarity cloudy, [MEDICATION NAME] positive A, leukocytes moderate, WBC (white blood cells) greater than 75, RBC (red blood cells) 4/6 A, bacteria large A. The physician was not notified that the C&S was not completed as ordered. On 03/03/11, the physician again ordered UA with C&S. A lab report, dated 03/03/11, revealed abnormal UA results (WBC greater that 75 and bacteria large). A gram stain report, dated 03/04/11, revealed: ""Moderate polymorphonuclear cells with many gram negative rods."" A final report, dated on 03/04/11, revealed: ""Greater than 100,000 cfu/ml Escherichia coli predominant organism with 25,000 to 50,000 cfu/ml mixed genital flora. Sensitive to [MEDICATION NAME]."" On 03/08/11, the physician ordered, ""[MEDICATION NAME] (an antibiotic) 500 mg every day for 10 days."" The C&S, which was not obtained until seven (7) days after ordered by the physician, confirmed the resident had a UTI. The bacteria count increased by 25,000 during this time frame and placed the resident at risk for further complications. The resident received treatment for [REDACTED]. An interview with the assistant director of nursing (ADON), on 03/10/11 at 1:45 p.m., revealed the C&S was not completed, because the nurse only sent only the request for a UA. ""If the C&S request is not sent to the lab separately, the lab will only do the urinalysis."" When she found out the nurse had not requested the C&S, she immediately told the nurse to call the physician, stating the physician may decide to prescribe a broad spectrum antibiotic until the urine culture could be completed. Instead, the physician ordered another UA with C&S on 03/03/11. After the C&S report was received by the facility, the physician treated the resident with an antibiotic.",2014-07-01
11174,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2011-03-30,225,D,1,0,SRCM11,". Based on record review and staff interview, the social worker failed to immediately report a family complaint containing allegations of neglect to the facility's administrator and to State officials as required by State law, and the facility failed to conduct a thorough investigation into these allegations of neglect. This practice affected one (1) of twelve (12) sampled residents. Resident identifier: 115. Facility census: 113. Findings include: a) Resident #115 Review of the facility's grievance / complaint records, at 3:50 p.m. on 03/28/11, disclosed the social worker (Employee #19) received a written complaint from Resident #115's family on 03/21/11, which stated stated Resident #115 reported to the family member that he had been left soiled for two (2) hours on two (2) separate occasions in the preceding days and that staff on night shift had turned his call light off and left him lying in bowel movement all night. Review of this complaint record found no evidence these allegations had been thoroughly investigated. When interviewed at that time, Employee #19 confirmed she took a complaint from Resident #115's spouse on 03/21/11. When asked about the facility's investigation into the concerns, Employee #19 stated, ""I asked some staff."" When asked if this complaint had been reported as an allegation of neglect, Employee #19 stated, ""No."" She further confirmed that she had not obtained written statements from employees, as part of a thorough investigation into these concerns. The administrator (Employee #16), when asked for the facility's record of abuse / neglect allegations that had been self-reported to State agencies, was asked if he had information related to the complaint filed by Resident #115's family. He said he did not know anything about the allegations made on behalf of this resident. Review of the facility's records of allegations of abuse / neglect that had been self-reported to State officials confirmed there was no evidence these allegations of neglect conveyed by Resident #115's family had been reported to State agencies as required. The facility started a formal investigation into the concerns expressed on behalf of Resident #115 on 03/28/11, and the allegations were self-reported to the appropriate State agencies on that date.",2014-07-01
11175,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-03-17,441,G,1,0,LHZ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, staff interview, review of facility policies, and review of information published by the Centers for Disease Control and Prevention (CDC), the facility failed to implement an infection control program effective in preventing the development and/or transmission of infections. This deficient practice affected three (3) of five (5) sampled residents. The facility caused harm to Resident #50, who was totally dependent on staff for all activities of daily living secondary to quadriplegia, by placing this compromised resident in a room with another resident (#2) who was being actively treated for [REDACTED]. Resident #50 subsequently developed a urinary tract infection with VRE as the infectious organism. The facility failed to appropriately cohort residents with multi-drug resistant organisms (MDRO), failed to assure the admissions coordinator was provided with information concerning residents with MDROs to assure compromised residents were not admitted into rooms occupied by residents with active or colonized infections, failed to assure licensed nurses utilized sanitary techniques while administering glucose testing, and failed to ensure direct care staff washed their hands prior to exiting an isolation room. These practices placed all residents at risk for more than minimal harm. Resident identifiers: #50, #24, and #26. Facility census: 96. Findings include: a) Resident #50 1. During the initial tour of this facility on 03/15/11 at 1:00 p.m., observation found Residents #2 and #50 were roommates in a semiprivate room. Observation noted an empty container of the intravenous (IV) antibiotic Invantz hanging from an IV pole next to Resident #50's bed. Further observation found Resident #50 had a recent tracheostomy (covered with a dressing) and a gastrostomy tube. - 2. Review of Resident #50's medical record revealed this [AGE] year old female was readmitted to the facility (into a semi-private room already occupied by Resident #2) on 02/16/11, following an acute hospital stay. According to her re-admission minimum data set (MDS) with an assessment reference date (ARD) of 02/21/11, Resident #50 did not have an infection with an MDRO and did not have a urinary tract infection (UTI) at the time of her readmission to the facility. In this MDS, the assessor also noted the resident had quadriplegia and was totally dependent upon staff for toilet use and personal hygiene. - 3. Review of Resident #2's medical record found a laboratory report, dated 02/18/11, documenting that Resident #2 had VRE in her urine. She was treated with [MEDICATION NAME]. Review of her physician orders [REDACTED]. Review of Resident #2's assessment information on her discharge record of 02/11/11, she was always incontinent of bladder and bowel and, like Resident #50, was totally dependent on staff for toilet use and personal hygiene. - 4. Review of Resident #50's medical record revealed that, after her return to the nursing home (at which time she was placed in the room already occupied by Resident #2), she tested positive for VRE in her urine on 02/26/11. - 5. According to the CDC: ""VRE is often passed from person to person by the contaminated hands of caregivers. VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. VRE is not spread through the air by coughing or sneezing."" (URL: http://www.cdc.gov/HAI/organisms/vre/vre.html) - 6. In an interview with the infection control nurse (Employee #21) and the director of nursing (DON) on 03/16/11 at 12:00 p.m., Employee #21 stated that, when she returned to the facility on Monday 02/28/11, she noted Resident #2 had not been properly placed on contact isolation, and she obtained a physician's orders [REDACTED]. Both employees agreed the facility's policy on cohorting had not been followed when Resident #50 was allowed to remain in the room with Resident #2 following the [DIAGNOSES REDACTED].#2's urine. Neither the DON nor the infection control nurse could provide evidence that Resident #50 had any history of VRE prior to this infection. - 7. Review of the facility's infection control policy (effective 8/2000) found the policy only addressed one (1) MDRO - Methicillin-resistant Staphylococcus aureus (MRSA). The policy had not been updated since August 2000 to include other MDROs, such as VRE. Both VRE and MRSA are considered MDROs requiring the implementation of transmission-based precautions. The policy contained the following language: ""2. If isolation or cohorting is not possible, residents who are colonized with MRSA... can be placed in a semiprivate room with a non-MRSA affected resident who is at low risk for developing infection. To be considered low risk the roommate: ... f) Should not have invasive devices such as tracheostomy tubes, gastrostomy tubes..."" - 8. An interview with a licensed practical nurse (LPN - Employee #100), on 03/16/11 at 12:00 p.m., elicited that she was the full time admissions coordinator who handled all admissions within the facility. She stated she worked Monday through Friday from 9:00 a.m. to 5:30 p.m. She expressed confusion concerning residents who were colonized with MDROs. She stated she was unaware that compromised residents could not be placed in the same room as residents with colonized MRSA, VRE, etc. She stated she thought only residents who were actively being treated for [REDACTED]. She also stated she was not provided a list of residents with a history of MDRO colonization. -- b) Residents #24, #50, and #26 1. A licensed practical nurse (LPN - Employee #66) was observed while administering a fingerstick and glucometer check to Resident #24 on the afternoon of 03/17/11. She prepared supplies for the procedure at her medication cart in the resident hallway. Without washing her hands, she procured gloves from a box on her medication cart and carried the supplies into the resident's room. She put on the gloves she had contaminated with her unwashed / unsanitized hands, cleaned the resident's finger with alcohol, and then stuck the resident's finger with a lancet. After obtaining the reading of 331 mg/dl, she cleaned the glucometer with alcohol, disposed of the lancet, removed her gloves, and then exited the room without washing her hands. Employee #66 returned to her cart and drew up the appropriate amount of insulin. She then noticed that Resident #24 was not in his room. She placed the insulin syringe in her med cart and walked up the hallway to retrieve the resident. She pushed the resident in his wheelchair into his room and returned to the medication cart. She was observed to remove her keys from her uniform pocket, touch her glasses, touch the cart, and remove the insulin syringe and alcohol pads from her cart. She was noted to repeatedly touch her hair to place it behind her ears. Without washing her hands, she procured gloves from a box on the medication cart and carried the supplies into the resident's room. Without washing her hands, she put on the contaminated gloves, cleaned the resident's left upper arm with alcohol, and administered the insulin. She disposed of the syringe, removed her gloves, and without washing her hands, exited the room and returned to her cart. - 2. Without washing her hands, Employee #66 then assembled supplies to perform a fingerstick on Resident #50 (recently treated for [REDACTED]. Without washing her hands, she put on gloves, cleaned the resident's finger with alcohol, and performed the fingerstick and glucometer test. She disposed of the lancet, removed her gloves, and without washing her hands, exited the room and returned to her cart. She then drew up the appropriate amount of insulin with her bare hands, placed the syringe on the top of the cart, and returned the insulin to her cart. She was again observed to repeatedly touch her hair and glasses. Without washing her hands, she obtained gloves from a box on the cart and carried the supplies to the resident's room. She placed the syringe on the overbed table without a clean field, donned her contaminated gloves, cleansed the resident's arm with alcohol, and administered the insulin. She then disposed of the syringe, removed her gloves, and without washing her hands, returned to her medication cart. Employee #66 prepared to move her cart to a different resident's room to perform a fingerstick when this surveyor reminded her that she had not washed her hands at any time during the observation. - 3. Observation of Employee #16 (an LPN), at 11:05 a.m. on 03/17/11, noted she touched the bedside table and contaminated her gloves prior to performing a fingerstick on Resident #26. -- c) A nursing assistant (Employee #49) was observed to assist Resident #25 following a vomiting episode at 8:30 a.m. on 03/16/11. Employee #49 then discarded her gloves in the resident's room and exited into the resident hallway without first washing her hands. Review of the medical record found Resident #25 was placed in a private isolation room for an upper respiratory MRSA infection. Review of the facility's isolation precaution policy (effective 8/2000) found the following: ""c. Gloves and Handwashing... 3. Remove gloves before leaving room and wash hands immediately with an antimicrobial agent...""",2014-07-01
11176,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-05-31,225,D,1,0,LHZ912,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interview, the facility failed to provide to the State agencies, in accordance with State law through established procedures, immediate and five (5) day follow-up reporting for a resident who sustained fractures of unknown etiology. This failure to meet the reporting requirements occurred for one (1) of twelve (12) sampled residents. Resident identifier: #16. Facility census: 97. Findings include: a) Resident #16 Review of nursing progress notes, dated 04/26/11 at 5:01 p.m., revealed the nurse was called to Resident #16's room by a certified nursing assistant (CNA). The nurse assessed the resident's right foot to be ""swollen, discolored, and tool to touch"". The CNA ""reports when putting pt (patient) back to bed leg noted to bent (sic) back underneath chair"". The physician was notified, and orders received for a portable x-ray of the right ankle. Further review of the nursing progress notes revealed an entry, made at 7:55 p.m. on 04/26/11, stating the x-ray revealed ""displaced fracture of distal tibia and fibular shafts""; the physician was notified and gave orders to transfer Resident #16 to the emergency room , which occurred at 8:56 p.m. Review of the x-ray report, dated 04/26/11, concluded Resident #16 had a [MEDICAL CONDITION] distal tibia and fibula; displacement angulation and overriding was seen; obvious extreme osteopenia was suggested; and etiology was unknown. Review of an operative report, dated 04/28/11, revealed preoperative and postoperative [DIAGNOSES REDACTED]. Review of a past complaint investigation conducted by the State survey and certification agency, dated 04/21/11, found Resident #16's behaviors of yelling and making noise were disturbing to some residents in her room and across the hall, and to some family members of Resident #16's roommates, and the facility was cited at that time for failing to address grievances voiced by residents about Resident #16's disruptive behaviors in a timely manner. During an interview on 05/30/11 at 12:40 p.m., an alert and oriented resident who had shared a room with Resident #16 stated she did not sleep much due to Resident #16, who screamed a lot; the roommate said Resident #16 would yell all night for a night or two, and then the next night she might sleep. The roommate said it had been this way all along since Resident #16 moved into their room. During an interview on 05/31/11 at 1:00 p.m., the director of nursing (DON) said they believed the fractures were pathological in nature and that they occurred during the transfer. They believed the injuries occurred during an witnessed event (the transfer); therefore, the cause of the fractures was presumed to have been known. Because the resident had a [DIAGNOSES REDACTED]. Therefore, the State survey and certification agency was not notified of the fractures. The facility's licensed social worker (LSW - Employee #99) concurred. During this same interview, the DON stated Resident #16 was gotten up in the chair on 04/26/11 in an effort to help her distinguish nights and days, so that she might sleep better and not disturb her roommates during the night. During further interview with Employee #99 on 05/31/11 at approximately 3:45 p.m., she reviewed the reporting guidelines and said she did not think the incident met the two-part criteria for reporting of an injury of unknown source. She stated the source of the injuries was observed by staff (when Resident #16 was either transferred to the chair or returned to the bed), and the injuries were not suspicious in nature. Review of the facility's internal investigation into Resident #16's fractures revealed an incident report completed on 04/26/11. The facility obtained witness statements from the two (2) nursing assistants who transferred Resident #16 to and from the chair and bed on 04/26/11, and they were unable to provide information as to how the fractures occurred or whether they were present when the fractures occurred. The witness statements revealed no mention of the resident having cried out in pain during the transfer, nor that they heard anything during the transfer that sounded as if bones were breaking. As noted above, the nurse stated, in her progress notes on 04/26/11 at 5:01 p.m., that the nursing assistant reported to her, when putting the resident back to bed, that the leg was found to be bent back underneath the chair, and the nurse found the right foot at that time to be ""swollen, discolored, and cool to touch"". There was no evidence to support the facility's belief that the fractures occurred during the transferring on 04/26/11; therefore, this was an injury of unknown source which should have been reported to State officials. .",2014-07-01
11177,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-05-31,323,D,1,0,LHZ912,". Based on observation and staff interview, the facility failed to ensure a hazard-free environment for one (1) of twelve (12) sampled residents. A cognitively impaired resident who received continuous gastrostomy tube feeding daily from 9:00 p.m. to 9:00 a.m. was housed in a room alone where she was not visible from the hallway. This action had the potential to cause more than minimal harm due to her being at risk for aspiration. Resident identifier: #16. Facility census: 97 Findings include: a) Resident #16 Observation of Resident #16, on 05/31/11 at approximately 5:50 a.m., found her sleeping in a private room on the rehabilitation unit where she could not be visualized from the hallway. To view the resident, one had to enter one room, turn right, take several steps, and pass through a doorway into another room before being able to see her head and upper body lying in her bed on the left. Osmolite feeding was hung and connected to her gastrostomy tube from the left side of her bed, but it was not infusing at this time. During an interview with the nurse (Employee #15) on 05/31/11 at 5:50 a.m., she said she arrived to work at 3:00 a.m. and found Resident #16 had been moved into the Lifeskills room on the rehabilitation unit the previous evening. She said, typically, this room was used for hospice patients and their families so they would have more privacy, or the room would be used to isolate residents with contagious pathogens. Employee #15 agreed that placing Resident #16 in this room presented a safety concern on night shift, especially since there was less staff going up and down the hall on this shift. She stated the gastrostomy tube was clogged, and she turned off the infusion until she could work on it, but it was ordered to infuse daily from 9:00 p.m. to 9:00 a.m. continuously. During an interview with another nurse (Employee #20) on 05/31/11 at 6:05 a.m., she said she did not like to have cognitively impaired residents such as Resident #16 to be far away from the nursing station, as she was now while located in the Lifeskills room; Employee #20 preferred only to have residents in that room who were alert and oriented and could ring the call bell. She agreed that Resident #16 was moved into that room sometime last evening before she came on duty. During an interview with another nurse (Employee #14) on 05/31/11 at 6:45 a.m., she agreed Resident #16 could not be visualized from the hallway, and she said she would do 15-minute checks on her until the tube feeding was completed, as it was running now. During interviews with Employees #20 and #22 (also a nurse) on 05/31/11 at 6:50 a.m., safety issues were discussed between the nurses about the resident not being able to be visualized from the hallway, and this nurse surveyor informed them that Employee #14 reported she would perform 15-minute checks on the resident until her tube feeding was finished. During an interview with the administrator on 05/31/11 at 7:45 a.m., safety issues were discussed regarding with Resident #16 receiving continuous gastrostomy tube feedings during the night and being housed in a room where she cannot be visualized from the hallway. The administrator considered moving Resident #16 to the front room of the 2-room Lifeskills unit where she could be visualized from the hallway. During an interview with the licensed social worker (LSW - Employee #99) on 05/31/11 at 8:30 a.m., she said she was unaware of the room change for Resident #16 until she came on duty this morning. She said she had another solution whereby a younger resident (who was alert and oriented) was agreeable to move into the Lifeskills room and give Resident #16 her bed in a semi-private room; the other resident in the semi- private room was currently hospitalized . During an interview with the director of nursing on 05/31/11 at 9:00 a.m., she stated moving Resident #16 into the Lifeskills room last evening was only meant to be a temporary move until they could find a permanent solution, in an effort to resolve a grievance between Resident #16 and a roommate who complained that Resident #16 deprived her of sleep due to noise she made. Later on 05/31/11, the room change was completed, and Resident #16 was able to be visualized from the hallway.",2014-07-01
11178,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2011-03-08,157,D,1,0,2ZE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to notify the legal representative one (1) of six (6) sampled residents after the resident sustained [REDACTED]. Resident identifier: #77. Facility census: 106. Findings include: a) Resident #77 Review of Resident #77's medical record revealed a Combined Medical Power of Attorney and Living Will document, dated 03/23/05, in which the resident designated a niece to serve as primary medical power of attorney representative (MPOA). In the event the niece was unable or unwilling to serve as a surrogate health care decision-maker, the resident designated a nephew to serve as the successor MPOA. Record review also revealed, on 09/13/06, the physician determined Resident #77 lacked the capacity to understand and make informed health care decisions. On this date, the MPOA document would have sprung into effect, with the resident's niece having the authority to make health care decisions on the resident's behalf. Review of the facility's records revealed an incident / accident report, dated 02/06/11, documenting that Resident #77 received a skin tear to the left upper arm measuring 1.5 cm x 0.5 cm. The resident's successor MPOA was notified of the skin tear at 1:00 p.m. that same day. There was no evidence in the resident's medical record to reflect the primary MPOA was unable or unwilling to serve; therefore, the primary MPOA (not the secondary MPOA) should have been notified of this injury. An interview with the director of nursing, on 03/09/10, confirmed staff notified the secondary MPOA, instead of the primary MPOA, of the resident's injury.",2014-07-01
11179,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,319,G,1,0,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not obtain psychological / psychiatrics services for a [AGE] year old male resident (#107) who was exhibiting an escalation in behaviors towards other residents, visitors, and staff that were socially and sexually inappropriate, verbally abusive, and physically aggressive. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, ""His behavior problem is not responding to SSRI's (selective serotonin reuptake inhibitors). I wonder if a medication such as [MEDICATION NAME] might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the [MEDICATION NAME] (medication to treat tremors). Follow-up can be arranged as needed."" The resident's attending physician and the facility's interdisciplinary care team members were aware that Resident #107's behaviors were escalating. However, no follow-up psychological or psychiatric services were sought by the facility after the increase in frequency of behaviors was noted by staff. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Documentation revealed Resident #107 displayed abusive and inappropriate behaviors towards at least four (4) identified residents (#108, #30, #110, and #14), and multiple unidentified residents, as well as multiple female staff members and visitors, and his behavior resulted in actual harm to a female activity staff member who sustained four (4) bruises on the left inner thigh after having been ""grabbed"" by him. Facility census: 106. Findings include: a) Resident #107 Medical record review, on 02/05/09 at 3:00 p.m., revealed Resident #107, prior to being discharged from the facility at 2:10 p.m. on 02/04/09, engaged in verbally abusive / physically aggressive and socially and sexually inappropriate behaviors towards other residents, female staff, and female visitors. Further review revealed the facility failed to implement interventions to protect residents, staff, and visitors from this resident's actions, even though Resident #107 had been exhibiting these behaviors for years. ---- 1. Record review revealed a [AGE] year old male was admitted to the facility from a rehabilitation hospital on [DATE], with [DIAGNOSES REDACTED]. A neuropsychological evaluation, dated 02/27/06, revealed the following: ""(Resident #107) currently resides at Heartland of [MEDICATION NAME] County Nursing Home where he has lived for several years. He has had increasing behavior difficulties at the nursing home, particularly over the last 6 months. These involve inappropriate sexual touching of staff, other residents, and visitors. He is also described by nursing staff to masturbate frequently, perhaps several times per day. The staff has attempted to modify his behavior by providing objects for his hands, redirecting his attention, reprimanding him, and engaging him in activities. . . . With prompts, (Resident #107) was able to state the concerns regarding his behavior, but showed a lack of appreciation of their significance. . . . (Resident #107) demonstrates severe cognitive impairment secondary to his significant closed head injury. Particular deficits were noted in motor skills, memory, processing, and frontal lobe functions. The patient has some relatively preserved cognitive functioning, which makes it seems as if his behavior is willful. However, the results of this evaluation indicate that he lacks sufficient cognitive ability to fully appreciate his behavior and/or inhibit it. It is recommended that a structured program be developed in which appropriate behaviors are differentially reinforced. . . . In addition, it is suggested that staff be trained and the patient's environment be structured with the goal of limiting opportunities for inappropriate behavior. Re-referral to a psychiatrist, ideally a neuropsychiatrist, is strongly recommended to determine whether medication may be effective in minimizing the patient's libido and managing his behavior."" A psychological consult, dated 05/08/06, contained the following recommendation: "". . . He currently displays a 'grasping reflex'. Any stimulation to the palm of the hand will engage a grabbing response. This may account for some of his 'inappropriate touching', as staff attempt to provide his care. He may benefit from grasping a substitute e.g. rolled washcloth, while care is being provided."" A neurology consult, dated 07/14/08, revealed the following: "". . . He (Resident #107) is now on [MEDICATION NAME] 20 milligrams/day for behavioral problems. He has some sexual (sic) aggressive behaviors involving grabbing at the nursing staff and other clients. Reportedly the [MEDICATION NAME] is not working. . . . His behavior problem is not responding to SSRI's. I wonder if a medication such as [MEDICATION NAME] might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the [MEDICATION NAME] (medication to treat tremors). Follow-up can be arranged as needed."" There was no evidence in Resident #107's medical record of efforts by the facility to obtain follow-up psychiatric and/or psychological services to address his sexually aggressive behaviors, after the 07/14/08 consult and prior to his discharge on 02/04/09. ---- 2. Review of Resident #107's medical record found no evidence of current quantitative and/or qualitative tracking of all of Resident #107's behaviors, although psychopharmacologic drug monthly flow records were completed for tracking the frequency at which Resident #107 was hitting, slamming doors, and intentionally backing his wheelchair into staff. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, over a 100-day period, documenting socially / sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Sixty-nine (69) entries recorded Resident #107 grabbing female staff, residents, and/or visitors on their breasts, buttocks, and inner thighs. Eighteen (18) entries recorded Resident #107 appearing outside of his room with no clothing on, exposing his genitalia to others. Twenty-seven (27) entries recorded Resident #107 wheeling his wheelchair backwards, creating a safety hazard for others. Twenty-seven (27) entries recorded episodes of Resident #107 verbally abusing / being physically aggressive towards others, including staff, other residents, and visitors; one (1) of these episodes resulted in an activity staff member receiving four (4) bruises to the left inner thigh. Four (4) entries recorded Resident #107 removing the incontinence brief from a severely cognitively impaired [AGE] year old female resident (#108), who was totally dependent upon staff for her activities of daily living. Entries included: On 10/28/08 at 2:45 p.m., "". . . Grabbing @ staff's bottom saying 'I want it.' Res became aggressive & mad @ staff when redirected & told him it was inappropriate behavior. Res hit two staff members & told this writter (sic) that if I ran my mouth he'd hit me too. . . . Tried to grab another staff member's bottom as he went down the hall."" On 10/29/08 at 6:30 p.m., "". . . Res (resident) inappropriately grabbed a female visitor awaiting trick or treating activity. Staff telling res that inappropriate behavior is not tolerated. Res going 'yea'."" On 11/05/08 at 11:40 p.m., ""Res tried to go into 400 hall main bathroom - alarm sounded. CNA's (certified nursing assistants) attempted to redirect res, whereupon res began yelling & hitting @ them. Res from room (number) was also in the hallway @ this x (time), mumbling to himself, which only made this res more upset. Res began yelling @ other man. . . ."" On 11/20/08 at 8:00 p.m., ""Res /c (with) behavior issues. Attempting to remove t-shirt while in dining room. Staff reporting Res became aggressive & went backwards in wc (wheelchair) spinning another res around in their wc. Notified nurse regarding other res to assess for any injuries. . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 11/22/08 at 7:00 p.m., "". . . It was reported by roommate that he (Resident #107) pushed table into roommate (sic) leg & messing /c TV."" On 12/03/08 at 6:45 p.m., ""Res in room /c all clothes off, lying in bed, masturbating. CNA's pulled curtain around resident. Res angry, got (arrow pointing up) in w/c per self, hitting @ staff & kicking. Cursing at staff saying 'You whore & [***] '. Res begins to chase CNAs down hallway & cursing, backing one CNA into corner & hitting @ CNA. . . ."" On 12/03/08 at 7:30 p.m., ""Res returned to hallway. Into another female resident's room, female res yelling 'help me, help me.' Res in room uncovered other resident & was attempting to unfasten resident's wing (incontinence brief) & had hand over wing & thigh area. Res removed from room & states 'I was trying to help her to the BR.' . . ."" (The female resident involved in this incident was Resident #108.) On 12/04/08 at 7:30 p.m., "". . . Res is grabbing at residents & staff. When redirected he gets verbally abusive & rams w/c into wall. When this writer explains to res that he can't do this (sic) his statement is 'I don't care.' . . ."" On 12/05/08 at 8:30 a.m., ""CNA went to let res know it was time for Breakfast. Res went to grab CNA. CNA stated 'Don't grab me.' Res then punched CNA in stomach. . . ."" On 12/13/08 at 3:30 p.m., ""Res wheeling self backward down hallway from room /c pants & underwear off. When res asked to get dressed, res laughing (sic) states 'I don't have too (sic).'. . ."" On 12/17/08 at 6:00 a.m., ""Res in female resident (sic) room, unfastened & opened res incontinence brief. When redirected to leave room & that it was inappropriate for him to be removing female resident (sic) clothes, (Resident #107) became agitated and attempted to back w/c into this writer. Removed from female (sic) room . . ."" (The female resident involved in this incident was Resident #108.) On 12/20/08 at 4:40 a.m., ""Called to floor by CNA's who had found resident again in female resident room. Res had unfastened female's incontinence brief and pulled it down, exposing female's peri-area. When resident told he needed to leave room & not enter again, he became agitated and telling this writer to 'shut up'. . . ."" (The female resident involved in this incident was Resident #108.) On 12/20/08 at 1:00 p.m., ""Res motivating (sic) w/c backward & yelling. This nurse tried to redirect, started asking him his multiplications. He then saw another res coming (sic) said 'I'm going to hit him in the damn head.' He then started for other res. Other res stepped out of way. This res cont. This nurse held w/c to keep him from running into other res. He then started hitting at this nurse. CNA came to help. Redirected res to cafe. Res then stripped off clothes. When ask (sic) why res stated to this nurse 'Your (sic) mean (sic) you didn't let me hit him.' This nurse explained 'I could not let that happen.' Res said 'You could have turned your head.' . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/21/08 at 6:30 p.m., ""Res found in female resident's room, had unfastened incontinence wing (brief), exposing resident. Res asked to leave room & that it is inappropriate to re-enter room. Cursing at staff. Wheeled self backwards & to room."" (The female resident involved in this incident was Resident #108.) On 12/23/08 at 2:20 p.m., ""Res going up hallway, Sally Ann's Dance girls, grabbing one of the dancers (sic) behind. Res redirected & taken to room."" On 12/24/08 at 11:30 a.m., ""Upon walking up 400 hall, CNA voiced that '(Resident #107) is in that room & won't come out.' Res did come out of room. When asked res to 'give me (other resident)'s stuff.' Res became very aggressive and hitting this writer. Asked res to stop and go back over to his own room, res repeatedly yelled, 'shut up', 'don't touch me.' No staff had touched res. Res pushed back to 100 hall. This writer walked past res approx(imately) 10 min(utes) later, res stated, 'Your ass is mine. I want your butt.' Told res to stop. Res voiced, 'no, I want your butt.' Unable to redirect res. . . ."" On 12/28/08 at 6:30 p.m., ""Res in w/c @ 4:15 p.m. motivating (sic) self backward. Ran w/c in to walker of another res, knocking it sideway (sic), Res stumbled, this nurse stopped res from falling. When redirected to (symbol for change) direction, Res grabbed this nurse by the arm, refusing to let go. Called for help & res released arm."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/04/09 at 3:30 p.m., "". . . (Arrow pointing up) in w/c (wheelchair) at present, going down hallway in w/c. Grabs another female resident by the breast & let go. When asked why he did that, res states while laughing 'because I want to.' . . ."" (The female resident involved in this incident was Resident #30.) On 01/10/09 at 10:00 a.m., "". . . Wheeled self into hallway /c lower portion of body exposed. Staff assisted res in dressing & asked res to please not come out of room undressed. Res laughed. Grabbed several female staff this a.m. (morning) on the buttocks. When asked not to do this he smiles (sic) & and stated 'But I want to.' . . ."" On 01/10/09 at 12:00 p.m., ""Res grabbed a visitor's buttocks /s (without) permission. Res redirected by staff & staff apologized to visitor. Res also entered female res rooms (sic) this am (morning) while res dressing. Res removed from room and returned to his hall area and explained to (sic) that his behavior is unacceptable. Res states 'I don't care.'"" On 01/11/09 at 2:00 a.m., ""Res (arrow pointing up) in w/c (arrow pointing up) & (arrow pointing down) hallway - removing clothes & going nude. Very aggressive when assisted to put clothes back on. . . ."" On 01/18/09 at 3:25 a.m., "". . . Propelling self backwards (arrow pointing up) & (arrow pointing down) hallway. Enc to turn & go forward for safety - res refused. Explained risk of running into walls, furniture, other people - Res states 'I won't.' Had near miss /c female resident who was ambulating in hallway. Conts /c grabbing @staff @times. . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/19/09 at 3:35 a.m., ""(Arrow pointing up) in w/c, frequently motivating (sic) self backwards. When asked to turn around, res becomes angry, states 'No! I don't want to' . . . In hallway /c bottom ? of body exposed. Redirected to room to dress."" On 01/20/09 at 3:40 a.m., ""Conts to propel self (arrow pointing up) hallway backwards. Attempts to redirect met /c aggression / swearing @ staff. Came (arrow pointing up) hallway /c bottom ? of body exposed. Asked to return to room to sleep or get clothes on. Res asked for assistance, then proceded (sic) to grope CNA repeatedly. Redirected /c res becoming verbally assaultive - calling staff '[***] es'. . . ."" On 12/22/08 at 4:00 a.m., ""Res in room (number) in bed #2. CNA (certified nursing assistant) awakened resident & told him to go to his own room/bed. Res got out of bed & into w/c. Grabbed CNA in chest and between legs. Redirected to inappropriateness of his actions. . . ."" On 01/25/09 at 6:40 p.m., "". . . Grabbing staff inappropriately (sic). This writer redirected him numerous x's (times). Res even grabed (sic) another res inapproately (sic). Was told he was not allowed to touch another res. His comment was 'Why not.'. . ."" (The female resident involved in this incident was Resident #14.) On 01/29/09 at 10:30 a.m., ""Reported to this nurse by activities director, activity person was grabbed on 1/27/09 by this Res. Activity staff person has (4) small round bruises on (L) (left) inner thigh at area."" On 01/30/09 at 10:00 p.m., ""Res (arrow pointing up) in w/c hitting staff & grabbing visitors. Hit CNA in this chest & this writer in the buttocks. Res was redirected & told not to behave in such a manner. He said 'Come on [***] (sic) & tried to run into us with this wheelchair."" On 02/02/09 at 8:30 p.m., ""Res in main lobby attempting to go out front door. Keepsafe alarm sounding. Res hitting nurse & CNA's attempting to re-direct res from door. Standing & yelling 'Come on [***] !' Cursed at visitor & young daughter, states 'F-ck you!' Re-directed to room /p (after) 5-10 mins (minutes). Res conts to yell at CNA's. . . ."" ---- 3. Review of Resident #107's physician progress notes [REDACTED]. On 07/15/08, ""(Resident #107) is generally stable. His (responsible party) did not want the use of jumpsuit. . . . He was seen by the neurologist and it was noted that he had a tremor, [MEDICAL CONDITION] bladder and behavior problems. . . ."" On 09/10/08, "". . . He has still been problematic with his aggressive sexual behavior here. Note from neurologist (from 07/14/08 consult) read regarding his tremor. . . . Also in regard to suggestion of [MEDICATION NAME] will try this in regard to his libido."" On 10/15/08, "". . . No changes in regard to tremor or behavior."" On 11/12/08, "". . . The same aggressive behavior still an issue here, especially among the female staff. . . . This pt (patient) will be transferred to services of Dr. (name). . . ."" On 12/10/08, ""(Resident #107) has a history of CHI (closed head injury) with secondary [DIAGNOSES REDACTED], dysarthria, gait disorder, sexual aggression, ? depression, overactive bladder and lately has been exhibiting some increasing aggression and inappropriate behavior including masturbating in front of anybody who may be around including children . . . History of CHI with increasing agitation and inappropriate behavior. We will continue his current meds but will also add on [MEDICATION NAME] 500 mg daily and monitor for affect (sic). . . ."" On 01/05/09, "". . . At last evaluation he was seen for some increasing aggression and inappropriate behavior and had [MEDICATION NAME] added. There has been minimal improvement with this and he actually had an interaction with another resident, which may result in him being removed from this facility. . . . There is the potential that the pt will be removed from the facility later this mth (month) due to his behavior. . . ."" ---- 4. Resident #107's social services progress notes recorded that Resident #107's behaviors, although chronic, were escalating. Although, medication adjustments were being made and (beginning in September 2008) the facility started exploring alternative placements for the resident, the resident's care plans were not revised when the interventions were found to be ineffective in controlling and/or reducing the resident's behaviors. ---- 5. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) identified that staff was to complete an incident /accident report when incidents resulted in resident injury; the DON reported Employee #21 was in charge of the incident / accident reports and additional questions would be needed directed to her. The DON also identified that the facility's administration did not believe Resident #107's behaviors were of a sexual nature (contrary to documentation found in nursing, social services, and physician progress notes [REDACTED]. When questioned about whether Resident #107 had received services from a mental health professional to address this increase in behaviors, since the resident's medical record revealed the last time he received the services of a psychologist was in 2006, the DON reviewed his record. Shortly thereafter, the DON acknowledged the facility did not refer Resident #107 for psychological or psychiatric services when he exhibited an increased frequency of behaviors at the end of October 2008. .",2014-07-01
11180,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,329,D,1,0,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not, for one (1) of twenty-two (22) sampled residents, ensure medications were not given for an excessive duration and that monitoring was completed to evaluate the effectiveness of the medication. [MEDICATION NAME] was given for greater than three (3) months, and [MEDICATION NAME] was given without laboratory monitoring to determine efficacy. Resident identifier: #107. Facility census: 106. Findings include: a) Resident #107 1. Medical record review, conducted on the morning of 02/05/09, revealed Resident #107 was receiving [MEDICATION NAME] since 05/17/08. Review of the original physician order [REDACTED]. According to http://www.mayoclinic.com/health/[MEDICATION NAME]/NS_patient-[MEDICATION NAME]: ""[MEDICATION NAME] should be used for short term therapy three (3) months or less and possible side effects include fatigue, dizziness, headache, irritability and sleepiness."" Review of the monthly drug regimen review found no evidence the consultant pharmacist had recognized as an irregularity that Resident #107 had been receiving this medication for an excessive duration. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) offered to review the medical record to determine whether the consultant pharmacist identified this irregularity. Shortly after this interview, the DON identified that the consultant pharmacist did not identify this irregularity until 02/02/09, and the consultant report was in a separate file for the physician to review; it was not in this resident's closed medical record. The facility failed to ensure that [MEDICATION NAME] was not given in an excessive duration. 2. Medical record review also revealed that, on 09/10/08, [MEDICATION NAME] 50 mg two (2) times a day for tremors was ordered. On 11/12/08, another order was written for [MEDICATION NAME] 25 mg every day at 1:00 p.m. On 12/17/08, laboratory testing revealed the resident's serum [MEDICATION NAME] level was 1.5 mg. Review of this document revealed the therapeutic range was 4-12 ug/ml. Following receipt of this laboratory report, the facility failed to make any adjustments to the medication in order to obtain the therapeutic drug range. According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm: ""Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations of [MEDICATION NAME] may be necessary for optimal dosage adjustment. The clinically effective serum level for [MEDICATION NAME] is between 5-12 ?g/mL."" .",2014-07-01
11181,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,428,E,1,0,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's dosing instructions, and staff interviews, it was determined the pharmacist had not identified drug irregularities for five (5) residents. The pharmacist had not identified the facility's current scheduling of antibiotics as an irregularity. The current schedules for antibiotics did not maintain blood levels of the medication for optimal effect. Two (2) of nineteen (19) residents on the sample were identified as being affected, and review of the February medication administration records (MAR) for the 100 hall identified an additional two (2) residents. Additionally, the pharmacist had not identified that Resident #107 was receiving Melatonin for an excessive duration. Resident identifiers: #52, #15, #95, and #51. Facility census: 106. Findings include: a) Residents #15, #51, #52, and #95 1. Resident #15 Review of the resident's medical record found that, on 01/19/09, Augmentin (an antibiotic) had been ordered given three (3) times a day pending the culture of the resident's tracheostomy site. Review of his MARs revealed the antibiotic had been scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. That meant the three (3) antibiotic doses were given in an approximately nine (9) hour period, leaving fifteen (15) hours between the 5:00 p.m. dose and the 8:00 a.m. dose on the following day. 2. Resident #51 The resident's current orders included Bactrim DS to be given twice a day for five (5) days. The antibiotic was scheduled for administration at 9:00 a.m. and 5:00 p.m. on the MAR. This schedule provided for the doses for one (1) day to be given eight (8) hours apart, and the next dose would not be given for approximately sixteen (16) hours. Review of the pharmacist's drug regimen review for Resident #51, dated 02/02/09, found the schedule for the Augmentin the resident received in January 2009 had not been noted as an irregularity. 3. Resident #52 The resident's current MAR indicated [REDACTED]. The antibiotic was scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. 4. Resident #95 A current order for Bactrim DS to be given twice a day for ten (10) days was noted on the resident's current MAR. The medication was scheduled to be given at 8:00 a.m. and 5:00 p.m. 5. The director of nursing was interviewed on 02/11/09. When asked about the scheduling of antibiotics, she was unable to offer a reason for the current schedules. She said that these were the schedules used for the medications ordered given two (2) or three (3) times a day - that she had not thought about the antibiotics. When asked whether the pharmacist had identified this as an irregularity in the reports she received, she said he/she had not. 6. Review of package inserts (obtained for in the Food and Drug Administration's website) from the pharmaceutical companies for each of these antibiotics found that, under the section for ""Dosage and Administration"", each included instructions that doses should be administered every twelve (12) hours if the medication was given twice a day and every eight (8) hours if given three (3) times a day. e) Resident #107 Medical record review, conducted on the morning of 02/05/09, revealed Resident #107 was receiving Melatonin since 05/17/08. Review of the original physician order [REDACTED]. According to http://www.mayoclinic.com/health/melatonin/NS_patient-melatonin: ""Melatonin should be used for short term therapy three (3) months or less and possible side effects include fatigue, dizziness, headache, irritability and sleepiness."" Review of the monthly drug regimen review found no evidence the consultant pharmacist had recognized as an irregularity that Resident #107 had been receiving this medication for an excessive duration. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) offered to review the medical record to determine whether the consultant pharmacist identified this irregularity. Shortly after this interview, the DON identified that the consultant pharmacist did not identify this irregularity until 02/02/09, and the consultant report was in a separate file for the physician to review; it was not in this resident's closed medical record. The facility failed to ensure that Melatonin was not given in an excessive duration.",2014-07-01
11182,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,498,D,1,0,IH3P11,"Based on observations, it was determined the facility had not ensured each nurse aide demonstrated competency in techniques necessary to care for residents' needs. A nursing assistant (NA) was observed assisting back to bed one (1) resident of random opportunity. The NA pulled a belt from under the resident after the resident was lying on her bed, creating a potential for shearing and/or friction injury to the resident. Resident identifier: #9. Facility census: 106. Findings include: a) Resident #9 On 02/10/09 at approximately 8:45 a.m., a NA (Employee #106) was observed assisting the resident from the bathroom to her bed. After the resident had lain down on the bed, she turned onto her left side. The NA released the fastening device and pulled the belt and the larger part of the fastening device under the resident's body, creating a potential for injury from shearing or friction, especially as the larger portion of the clasp was pulled beneath the resident. .",2014-07-01
11183,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,323,G,1,0,IH3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not provide adequate supervision to prevent a [AGE] year old male resident (#107) from being socially and sexually inappropriate, verbally abusive, and physically aggressive towards staff, other residents, and visitors. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, ""His behavior problem is not responding to SSRI's (selective serotonin reuptake inhibitors). I wonder if a medication such as Proscar might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the Primidone (medication to treat tremors). Follow-up can be arranged as needed."" The resident's attending physician and the facility's interdisciplinary care team members were aware that Resident #107's behaviors were escalating. However, no follow-up psychological or psychiatric services were sought by the facility after the increase in frequency of behaviors was noted by staff. Although the resident's medication regimen was periodically adjusted to address his behaviors, review of his care plans for ""inappropriate touching"", physical and verbal aggression, ""inappropriate dressing"", and wheeling his wheelchair backwards revealed the goals were not always realistic and/or measurable, and the interventions were not revised when it should have been evident to the interdisciplinary care team, based on the numerous entries in the nursing notes from October 2008 to the date of the resident's discharge on 02/04/09, that the interventions were not effective in achieving the stated goals. Although the facility, according to social service progress notes beginning in 09/18/08, identified the need for alternative placement for this very young resident with sexually aggressive behaviors, none of the care plans included providing increased supervision to protect other residents, staff, and visitors from Resident #107's behaviors until such alternative placement could be found. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Documentation revealed Resident #107 displayed abusive and inappropriate behaviors towards at least four (4) identified residents (#108, #30, #110, and #14), and multiple unidentified residents, as well as multiple female staff members and visitors, and his behavior resulted in actual harm to a female activity staff member who sustained four (4) bruises on the left inner thigh after having been ""grabbed"" by him. Facility census: 106. Findings include: a) Resident #107 Medical record review, on 02/05/09 at 3:00 p.m., revealed Resident #107, prior to being discharged from the facility at 2:10 p.m. on 02/04/09, engaged in verbally abusive / physically aggressive and socially and sexually inappropriate behaviors towards other residents, female staff, and female visitors. Further review revealed the facility failed to implement interventions to protect residents, staff, and visitors from this resident's actions, even though Resident #107 had been exhibiting these behaviors for years. ---- 1. Record review revealed a [AGE] year old male was admitted to the facility from a rehabilitation hospital on [DATE], with [DIAGNOSES REDACTED]. A neuropsychological evaluation, dated 02/27/06, revealed the following: ""(Resident #107) currently resides at Heartland of Preston County Nursing Home where he has lived for several years. He has had increasing behavior difficulties at the nursing home, particularly over the last 6 months. These involve inappropriate sexual touching of staff, other residents, and visitors. He is also described by nursing staff to masturbate frequently, perhaps several times per day. The staff has attempted to modify his behavior by providing objects for his hands, redirecting his attention, reprimanding him, and engaging him in activities. . . . With prompts, (Resident #107) was able to state the concerns regarding his behavior, but showed a lack of appreciation of their significance. . . . (Resident #107) demonstrates severe cognitive impairment secondary to his significant closed head injury. Particular deficits were noted in motor skills, memory, processing, and frontal lobe functions. The patient has some relatively preserved cognitive functioning, which makes it seems as if his behavior is willful. However, the results of this evaluation indicate that he lacks sufficient cognitive ability to fully appreciate his behavior and/or inhibit it. It is recommended that a structured program be developed in which appropriate behaviors are differentially reinforced. . . . In addition, it is suggested that staff be trained and the patient's environment be structured with the goal of limiting opportunities for inappropriate behavior. Re-referral to a psychiatrist, ideally a neuropsychiatrist, is strongly recommended to determine whether medication may be effective in minimizing the patient's libido and managing his behavior."" A psychological consult, dated 05/08/06, contained the following recommendation: "". . . He currently displays a 'grasping reflex'. Any stimulation to the palm of the hand will engage a grabbing response. This may account for some of his 'inappropriate touching', as staff attempt to provide his care. He may benefit from grasping a substitute e.g. rolled washcloth, while care is being provided."" A neurology consult, dated 07/14/08, revealed the following: "". . . He (Resident #107) is now on Paxil 20 milligrams/day for behavioral problems. He has some sexual (sic) aggressive behaviors involving grabbing at the nursing staff and other clients. Reportedly the Paxil is not working. . . . His behavior problem is not responding to SSRI's. I wonder if a medication such as Proscar might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the Primidone (medication to treat tremors). Follow-up can be arranged as needed."" There was no evidence in Resident #107's medical record of efforts by the facility to obtain follow-up psychiatric and/or psychological services to address his sexually aggressive behaviors, after the 07/14/08 consult and prior to his discharge on 02/04/09. ---- 2. Review of Resident #107's medical record found no evidence of current quantitative and/or qualitative tracking of all of Resident #107's behaviors, although psychopharmacologic drug monthly flow records were completed for tracking the frequency at which Resident #107 was hitting, slamming doors, and intentionally backing his wheelchair into staff. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, over a 100-day period, documenting socially / sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. --- Sixty-nine (69) entries recorded Resident #107 grabbing female staff, residents, and/or visitors on their breasts, buttocks, and inner thighs. Examples of these entries include: On 10/29/08 at 6:30 p.m., "". . . Res (resident) inappropriately grabbed a female visitor awaiting trick or treating activity. Staff telling res that inappropriate behavior is not tolerated. Res going 'yea'."" On 12/22/08 at 4:00 a.m., ""Res in room (number) in bed #2. CNA (certified nursing assistant) awakened resident & told him to go to his own room/bed. Res got out of bed & into w/c. Grabbed CNA in chest and between legs. Redirected to inappropriateness of his actions. . . ."" On 12/23/08 at 2:20 p.m., ""Res going up hallway, Sally Ann's Dance girls, grabbing one of the dancers (sic) behind. Res redirected & taken to room."" On 01/04/09 at 3:30 p.m., "". . . (Arrow pointing up) in w/c (wheelchair) at present, going down hallway in w/c. Grabs another female resident by the breast & let go. When asked why he did that, res states while laughing 'because I want to.' . . ."" (The female resident involved in this incident was Resident #30.) On 01/10/09 at 12:00 p.m., ""Res grabbed a visitor's buttocks /s (without) permission. Res redirected by staff & staff apologized to visitor. Res also entered female res rooms (sic) this am (morning) while res dressing. Res removed from room and returned to his hall area and explained to (sic) that his behavior is unacceptable. Res states 'I don't care.'"" On 01/10/09 at 7:40 p.m., ""Res repeatedly unzipped pants asking asking (sic) staff to zip them now. Res entered soil (sic) utility room grabbing laundry person."" On 01/14/09 at 4:00 a.m., "". . . Conts (continues) to grab @ staff @ times. Re-directed, res just grins @ staff and reaches for staff again. . . ."" On 01/25/09 at 6:40 p.m., "". . . Grabbing staff inappropriately (sic). This writer redirected him numerous x's (times). Res even grabed (sic) another res inapproately (sic). Was told he was not allowed to touch another res. His comment was 'Why not.'. . ."" (The female resident involved in this incident was Resident #14.) On 01/29/09 at 10:30 a.m., ""Reported to this nurse by activities director, activity person was grabbed on 1/27/09 by this Res. Activity staff person has (4) small round bruises on (L) (left) inner thigh at area."" --- Eighteen (18) entries recorded Resident #107 appearing outside of his room with no clothing on, exposing his genitalia to others. Examples of these entries include: On 12/13/08 at 3:30 p.m., ""Res wheeling self backward down hallway from room /c pants & underwear off. When res asked to get dressed, res laughing (sic) states 'I don't have too (sic).'. . ."" On 01/10/09 at 10:00 a.m., "". . . Wheeled self into hallway /c lower portion of body exposed. Staff assisted res in dressing & asked res to please not come out of room undressed. Res laughed. Grabbed several female staff this a.m. (morning) on the buttocks. When asked not to do this he smiles (sic) & and stated 'But I want to.' . . ."" On 01/11/09 at 2:00 a.m., ""Res (arrow pointing up) in w/c (arrow pointing up) & (arrow pointing down) hallway - removing clothes & going nude. Very aggressive when assisted to put clothes back on. . . ."" On 01/19/09 at 3:35 a.m., ""(Arrow pointing up) in w/c, frequently motivating (sic) self backwards. When asked to turn around, res becomes angry, states 'No! I don't want to' . . . In hallway /c bottom ? of body exposed. Redirected to room to dress."" --- Twenty-seven (27) entries recorded Resident #107 wheeling his wheelchair backwards, creating a safety hazard for others. Examples of these entries include: On 11/20/08 at 8:00 p.m., ""Res /c (with) behavior issues. Attempting to remove t-shirt while in dining room. Staff reporting Res became aggressive & went backwards in wc (wheelchair) spinning another res around in their wc. Notified nurse regarding other res to assess for any injuries. . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/28/08 at 6:30 p.m., ""Res in w/c @ 4:15 p.m. motivating (sic) self backward. Ran w/c in to walker of another res, knocking it sideway (sic), Res stumbled, this nurse stopped res from falling. When redirected to (symbol for change) direction, Res grabbed this nurse by the arm, refusing to let go. Called for help & res released arm."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/18/09 at 3:25 a.m., "". . . Propelling self backwards (arrow pointing up) & (arrow pointing down) hallway. Enc to turn & go forward for safety - res refused. Explained risk of running into walls, furniture, other people - Res states 'I won't.' Had near miss /c female resident who was ambulating in hallway. Conts /c grabbing @staff @times. . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) --- Twenty-seven (27) entries recorded episodes of Resident #107 verbally abusing / being physically aggressive towards others, including staff, other residents, and visitors. Examples of these entries include: On 10/28/08 at 2:45 p.m., "". . . Grabbing @ staff's bottom saying 'I want it.' Res became aggressive & mad @ staff when redirected & told him it was inappropriate behavior. Res hit two staff members & told this writter (sic) that if I ran my mouth he'd hit me too. . . . Tried to grab another staff member's bottom as he went down the hall."" On 11/05/08 at 11:40 p.m., ""Res tried to go into 400 hall main bathroom - alarm sounded. CNA's (certified nursing assistants) attempted to redirect res, whereupon res began yelling & hitting @ them. Res from room (number) was also in the hallway @ this x (time), mumbling to himself, which only made this res more upset. Res began yelling @ other man. . . ."" On 11/22/08 at 7:00 p.m., "". . . It was reported by roommate that he (Resident #107) pushed table into roommate (sic) leg & messing /c TV."" On 12/03/08 at 6:45 p.m., ""Res in room /c all clothes off, lying in bed, masturbating. CNA's pulled curtain around resident. Res angry, got (arrow pointing up) in w/c per self, hitting @ staff & kicking. Cursing at staff saying 'You whore & [***] '. Res begins to chase CNAs down hallway & cursing, backing one CNA into corner & hitting @ CNA. . . ."" On 12/04/08 at 7:30 p.m., "". . . Res is grabbing at residents & staff. When redirected he gets verbally abusive & rams w/c into wall. When this writer explains to res that he can't do this (sic) his statement is 'I don't care.' . . ."" On 12/05/08 at 8:30 a.m., ""CNA went to let res know it was time for Breakfast. Res went to grab CNA. CNA stated 'Don't grab me.' Res then punched CNA in stomach. . . ."" On 12/20/08 at 1:00 p.m., ""Res motivating (sic) w/c backward & yelling. This nurse tried to redirect, started asking him his multiplications. He then saw another res coming (sic) said 'I'm going to hit him in the damn head.' He then started for other res. Other res stepped out of way. This res cont. This nurse held w/c to keep him from running into other res. He then started hitting at this nurse. CNA came to help. Redirected res to cafe. Res then stripped off clothes. When ask (sic) why res stated to this nurse 'Your (sic) mean (sic) you didn't let me hit him.' This nurse explained 'I could not let that happen.' Res said 'You could have turned your head.' . . ."" (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/24/08 at 11:30 a.m., ""Upon walking up 400 hall, CNA voiced that '(Resident #107) is in that room & won't come out.' Res did come out of room. When asked res to 'give me (other resident)'s stuff.' Res became very aggressive and hitting this writer. Asked res to stop and go back over to his own room, res repeatedly yelled, 'shut up', 'don't touch me.' No staff had touched res. Res pushed back to 100 hall. This writer walked past res approx(imately) 10 min(utes) later, res stated, 'Your ass is mine. I want your butt.' Told res to stop. Res voiced, 'no, I want your butt.' Unable to redirect res. . . ."" On 01/20/09 at 3:40 a.m., ""Conts to propel self (arrow pointing up) hallway backwards. Attempts to redirect met /c aggression / swearing @ staff. Came (arrow pointing up) hallway /c bottom ? of body exposed. Asked to return to room to sleep or get clothes on. Res asked for assistance, then proceded (sic) to grope CNA repeatedly. Redirected /c res becoming verbally assaultive - calling staff '[***] es'. . . ."" On 01/30/09 at 10:00 p.m., ""Res (arrow pointing up) in w/c hitting staff & grabbing visitors. Hit CNA in this chest & this writer in the buttocks. Res was redirected & told not to behave in such a manner. He said 'Come on [***] (sic) & tried to run into us with this wheelchair."" On 02/02/09 at 8:30 p.m., ""Res in main lobby attempting to go out front door. Keepsafe alarm sounding. Res hitting nurse & CNA's attempting to re-direct res from door. Standing & yelling 'Come on [***] !' Cursed at visitor & young daughter, states 'F-ck you!' Re-directed to room /p (after) 5-10 mins (minutes). Res conts to yell at CNA's. . . ."" --- Four (4) entries recorded Resident #107 removing the incontinence brief from a severely cognitively impaired [AGE] year old female resident (#108), who was totally dependent upon staff for her activities of daily living. On 12/03/08 at 7:30 p.m., ""Res returned to hallway. Into another female resident's room, female res yelling 'help me, help me.' Res in room uncovered other resident & was attempting to unfasten resident's wing (incontinence brief) & had hand over wing & thigh area. Res removed from room & states 'I was trying to help her to the BR.' . . ."" On 12/17/08 at 6:00 a.m., ""Res in female resident (sic) room, unfastened & opened res incontinence brief. When redirected to leave room & that it was inappropriate for him to be removing female resident (sic) clothes, (Resident #107) became agitated and attempted to back w/c into this writer. Removed from female (sic) room . . ."" On 12/20/08 at 4:40 a.m., ""Called to floor by CNA's who had found resident again in female resident room. Res had unfastened female's incontinence brief and pulled it down, exposing female's peri-area. When resident told he needed to leave room & not enter again, he became agitated and telling this writer to 'shut up'. . . ."" On 12/21/08 at 6:30 p.m., ""Res found in female resident's room, had unfastened incontinence wing (brief), exposing resident. Res asked to leave room & that it is inappropriate to re-enter room. Cursing at staff. Wheeled self backwards & to room."" (Note that Resident #108 was discharged from the facility on 01/06/09.) ---- 3. Review of Resident #107's physician progress notes [REDACTED]. On 12/17/07, "". . . There have been no acute episodes although his behavior is not any better. . . ."" On 01/16/08, "". . . His behavior however has not improved. . . ."" On 02/13/08, "". . . His behavior is about the same. . . ."" On 05/15/08, "" . . His behaviors are not improved. . . ."" On 06/13/08, ""I have an extensive conversation with (Resident #107's responsible party). There have been some behavioral problems in regard to exposing himself and also with smearing feces. . . . A jumpsuit has been ordered and the use of this and timing were discussed. . . ."" On 07/15/08, ""(Resident #107) is generally stable. His (responsible party) did not want the use of jumpsuit. . . . He was seen by the neurologist and it was noted that he had a tremor, neurogenic bladder and behavior problems. . . ."" On 09/10/08, "". . . He has still been problematic with his aggressive sexual behavior here. Note from neurologist (from 07/14/08 consult) read regarding his tremor. . . . Also in regard to suggestion of Proscar will try this in regard to his libido."" On 10/15/08, "". . . No changes in regard to tremor or behavior."" On 11/12/08, "". . . The same aggressive behavior still an issue here, especially among the female staff. . . . This pt (patient) will be transferred to services of Dr. (name). . . ."" On 12/10/08, ""(Resident #107) has a history of CHI (closed head injury) with secondary [DIAGNOSES REDACTED], dysarthria, gait disorder, sexual aggression, ? depression, overactive bladder and lately has been exhibiting some increasing aggression and inappropriate behavior including masturbating in front of anybody who may be around including children . . . History of CHI with increasing agitation and inappropriate behavior. We will continue his current meds but will also add on Depakote 500 mg daily and monitor for affect (sic). . . ."" On 01/05/09, "". . . At last evaluation he was seen for some increasing aggression and inappropriate behavior and had Depakote added. There has been minimal improvement with this and he actually had an interaction with another resident, which may result in him being removed from this facility. . . . There is the potential that the pt will be removed from the facility later this mth (month) due to his behavior. . . ."" ---- 4. Resident #107's social services progress notes recorded that Resident #107's behaviors, although chronic, were escalating. Although, medication adjustments were being made and (beginning in September 2008) the facility started exploring alternative placements for the resident, the resident's care plans were not revised when the interventions were found to be ineffective in controlling and/or reducing the resident's behaviors. Examples of entries include: On 12/20/07, "". . . he has been displaying the following behavior problems: exit seeking (he is in the Exit (sic) seeking program & has orders for a secure care bracelet), resisting care (refusing medications - stating 'I don't want it') and socially inappropriate behavior AEB (as evidence by) defacating (sic) in his bed & then eating the feces. Care plans for these problems have been developed, revised, and/or continued. Res has not shown the following behavior problems during this assessment period. However, the care plans will be continued @ least until next review: (1) taking things that don't belong to him (ex. food), inappropriate dressing AEB being naked in public area, physical aggression d/t wheeling backward when upset (Res hit someone while doing this previously), and inappropriate sexual behavior as evidenced by grabbing or touching others on private areas of their bodies. . . ."" On 03/20/08, "". . . Resident has Behavior (sic) problems i (1) episode of verbal abuse to staff (sic) ii (2) episodes of lacking clothes off & Being (sic) in hallway naked. . . ."" On 04/07/08, "". . . Apparently, Res was in his room /c the door closed during the (fire) drill. A CNA went down the hallway opening Resident's (sic) doors. She opened (Resident #107)'s door & he allegedly slammed it shut on her fingers & toe which caused minor injuries. . . ."" On 06/20/08, "". . . He continues to have other behaviors such as grabbing other individuals on inappropriate areas of their bodies, yelling @ staff, hitting @ staff, refusing medications, & wheeling his w/c backwards. . . ."" On 09/18/08, "". . . Res is still exhibiting several behavior problems that include: exit seeking, physically & verbally abusive, going backward in his w/c, coming out into public areas /c 0 (no) pants on, touching / grabbing others inappropriately & refusing medications. . . This writer spoke with Res about all of these behaviors. He denied being physically abusive to staff. Otherwise, he had no explanation for the remaining behaviors. MD did order Proscar 5 mg q (every) day for (arrow pointing up)'d libido. . . ."" On 12/12/08, ""This writer was on telephone /c a family member when Res came into office unnoticed a (sic) grabbed this writer around waist / stomach area from behind. This writer attempted to push his arm / hand away. When I finally got him to remove his arm, I turned around & he had his arm raised, hand balled in a fist, as if he were going to punch this writer. However, he did not. . . ."" On 12/18/08, ""Resident's behavior seems to have been escalating over the last couple of months. Behaviors include: verbally abusive behavior (cursing @ staff), physically abusive behavior (hitting & punching staff, chasing staff, running into other /c w/c while going backward), socially inappropriate / disruptive behavior (slamming doors, going into other residents' rooms, removing his clothing in public, attempting to fondle female Resident & grabbing others on inappropriate areas of their bodies (sic), and resisting care (refusing meds). . . . MD did order Proscar for (arrow pointing up) libido but this does not appear effective. On 12/10/08, MD ordered 500 mg q day for CHI /c behaviors."" On 12/18/08, ""Late entry for 11/25/08. Res moved to room (number). Will monitor for any adjustment problems."" On 12/18/08, ""This writer has talked to Res about his new room a couple x's (times) & he has stated that he likes it. Res is having behaviors problems - but these are chronic & started escalating prior to his move."" On 12/22/08, ""(Resident's responsible party) (sic) in person @ facility. Res behaviors were explained to her & that they are now not only affecting staff but other residents as well. She agreed to work /c us on a transfer to a more appropriate facility. . . (Resident's responsible party) will look over info from other facilities & we will proceed /c any other referrals per her request. NHA (nursing home administrator) did explain that facility was going to issue a d/c (discharge) notice. (Responsible party) was understanding. . ."" On 01/02/09, ""(Resident #107)'s roommate requested a rm (room) (symbol for change) stating he could not be in room /c (Resident #107) for one more day d/t behaviors. Roommate to be moved this evening."" On 02/04/09, ""Res transferred to (area hospital) in hopes of admission to (area in-patient psychiatric facility) for behavioral eval. His Depakote was d/c'd (discontinued) d/t (arrow pointing up) liver enzymes & this may present a problem."" ---- 5. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) identified that staff was to complete an incident /accident report when incidents resulted in resident injury; the DON reported Employee #21 was in charge of the incident / accident reports and additional questions would be needed directed to her. The DON also identified that the facility's administration did not believe Resident #107's behaviors were of a sexual nature (contrary to documentation found in nursing, social services, and physician progress notes [REDACTED]. When questioned about whether Resident #107 had received services from a mental health professional to address this increase in behaviors, since the resident's medical record revealed the last time he received the services of a psychologist was in 2006, the DON reviewed his record. Shortly thereafter, the DON acknowledged the facility did not refer Resident #107 for psychological or psychiatric services when he exhibited an increased frequency of behaviors at the end of October 2008. During an interview on the morning of 02/12/09, the director of care delivery (Employee #21) confirmed that incident / accident reports were completed on incidents resulting in resident injuries. However, no incident / accident reports were completed for the occurrences referenced above, nor was the frequency of these occurrences (verbally abusive / physically aggressive and/or socially and sexually inappropriate behaviors) being tracked in any way. (See citation at N362 for non-compliance with the State licensure rule, for failing to complete written reports for incidents / accidents involving residents either inside or outside of the nursing home.) ---- 6. Review of the resident's nursing notes revealed that, when Resident #107 exhibited these behaviors, staff responded by attempting to ""redirect"" him and informing him that his behaviors were ""inappropriate"". As evidenced by the frequent recurrence of the behaviors, these interventions were ineffective. Review of his care plan revealed a plan to address ""inappropriate touching behavior"" which was initiated on 12/19/06. The goal for this problem (""Reduced incidents of inappropriate sexual behavior thru next care plan review"") was initiated on 12/19/06 and remained unchanged through present date; this goal was not measurable, as the facility failed to establish a baseline frequency for this behavior and failed to quantitatively and qualitatively document when Resident #107 exhibited this behavior. The interventions to achieve this goal remained essentially unchanged since revised on 12/18/08, although two (2) interventions were revised on 02/05/09, the day after he was discharged from the facility. Documentation in the nursing notes, from December 2008 through his date of discharge on 02/04/09, revealed he engaged in this behavior multiple times weekly, even multiple times daily, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address physical and verbal aggression (""Physical and verbal aggression (hitting, punching, cursing at others {sic} (usually staff) and slamming doors related to: closed head injury.""), which was initiated on 06/19/07. The goals for this problem (""Will not harm self or others during periods of physical aggression"" and ""Will not verbally abuse others"") were initiated on 06/19/07 and remained unchanged since that date. The interventions were last revised on 09/19/08. Documentation in the nursing notes, from October 2008 through his date of discharge on 02/04/09, revealed he engaged in this behaviors multiple times weekly, sometimes multiple times daily, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address ""wheeling his wheelchair backwards into other individuals"", which was initiated n 06/20/08. The goal for this problem (""Resident will wheel himself forward in his wheelchair."") was initiated on 06/20/08 and remained unchanged since that date. The interventions were last revised on 06/20/08, and consisted of the following: ""Notify physician of behaviors as necessary. Ask resident nicely to turn his wheelchair around. Explain to resident in simple terms that he could hurt someone d/t (due to) not being able to see where he is going. Don't lecture Resident (sic). Present resolution of turning wheelchair around as a huge favor to you."" Documentation in the nursing notes, from October 2008 through his date of discharge on 02/04/09, revealed he engaged in this behaviors multiple times weekly, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address ""inappropriate dressing (being in public area without appropriate clothing on)"", which was initiated on 09/17/07. The goal for this problem (""Will have neat and",2014-07-01
11184,"WEIRTON MEDICAL CENTER, D/P",515077,601 COLLIERS WAY,WEIRTON,WV,26062,2009-05-20,465,D,1,0,V0TW11,"Guidelines for Design and Construction of Health Care Facilities 2 Building Systems 2.1 Plumbing 2.1.1 General. Unless otherwise specified herein, all plumbing systems shall be designed and installed in accordance with the International Plumbing Code. 2.1.2 Plumbing and Other Piping Systems 2.1.2.1 Hot water systems. The following standards shall apply to hot water systems: *(1) Capacity. The water-heating system shall have sufficient supply capacity at the temperatures and amounts indicated in the applicable table. Storage of water at higher temperatures shall be permitted. (2) Hot water distribution systems serving patient/resident care areas shall be under constant recirculation to provide continuous hot water. This Standard is Not Met as evidenced by: Based on measured water temperatures, the facility failed to provide continuous hot water at the required temperatures indicated in Table 4.1-3 (95 - 110 degrees Fahrenheit (F)). Facility census: 28. Findings include: a) At approximately 10:50 a.m. on 05/19/09, hot water temperature was measured in the sink serving resident room #630. The hot water temperature at this sink was measured to be 65.9 degrees F after heavily flowing water for four (4) minutes. The hot water temperature at a second sink serving the Ante-room portion of this resident room was measured at 66.0 degrees F initially and rose to 108.0 degrees F after three (3) minutes. The hot water temperature of the first sink was re-measured and found to be 108 degrees F. To conclude, a time frame of seven (7) minutes was required to obtain an acceptable hot water temperature and continuous hot water is not provided. As such, the comfort of the resident is compromised. .",2014-07-01
11185,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-07-09,514,D,1,0,N19U11,". Based on medical record review, review of self-reported allegations of abuse / neglect, staff interview, and review of the American Health Information Management Association (AHIMA) Long-Term Care Health Information and Documentation Guidelines (revised June 2009), the facility failed to maintain clinical records in accordance with professional standards that are complete and accurate for one (1) of three (3) sampled residents. Resident #30's nurse aide reported to her charge nurse that the resident's right leg was swollen and it appeared sore. The charge nurse did not document any assessment performed on this resident in the medical record. Resident identifier: #30. Facility census: 65. Findings include: a) Resident #30 A review of the facility's internal investigation into Resident #30's fractured right distal femur revealed the facility had taken statements from staff members regarding the fracture. In an statement written by Employee #9 (a nurse aide), Employee #9 indicated Employee #18 (another nurse aide) had informed her, on 06/18/10, that Resident #30's right knee was swollen and appeared to be sore. Employee #18, in turn, stated she reported this to the evening shift charge nurse. An interview with the director of nursing (DON), in the early afternoon on 07/08/10, found Employee #29 (a registered nurse - RN) served as the charge nurse on the evening of 06/18/10. Further review of the facility's internal investigation revealed Employee #29 had not documented in Resident #30's medical record any assessment made of the resident after receiving this information from Employee #18. On 07/08/10 at approximately 4:00 p.m., Employee #29 came into the facility and provided a statement regarding her knowledge of Resident #30's right leg fracture. The statement read as follows: ""(Resident #30's name) complained freq. (frequently) of having leg pain at various times while in the dining room. (Family member's name) would discuss her arthritis and (family member's name) would suggest we give her Tylenol after dinner and put her back to bed. On this recent occurrence the 18th of June (sic) a CNA reported her knee was swollen (sic) I assessed both knees and they were swollen (sic) the R (right) knee more so than the L (left). I mentioned this to (family member's name) when I spoke with her she stated that's her arthritis. We again discussed giving her Tylenol and putting her to bed after dinner."" Employee #29 had provided no documentation regarding this assessment of Resident #30 until 07/08/10, after the surveyor had questioned the issue. In an interview with the DON and administrator on the morning of 07/09/10, both confirmed there was no documentation of a nursing assessment of Resident #30 in her chart on 06/18/10. The administrator and the DON agreed that Employee #29 should have documented her assessment of Resident #30 on the actual date the assessment took place. -- According to the professional standards and practices established by the AHIMA (which can be accessed via the Internet at: ), under the heading ""5. LEGAL DOCUMENTATION STANDARDS"": ""9. Completeness ""Document all facts and pertinent information related to an event, course of treatment, resident condition and deviation from standard treatment (including the reason for it). Make sure every entry is complete and contains all significant information. If the original entry is incomplete follow guidelines for making a late entry, addendum or clarification."" ""15. Condition Changes ""Every change in a resident's condition or a significant resident care issue must be noted and charted until the resident condition is resolved. Documentation that provides evidence of follow through is critical.""",2014-07-01
11186,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-11-12,225,D,1,0,OP3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, staff interview, review of personnel records, and policy review, the facility failed to ensure all allegations of abuse / neglect were immediately reported (in accordance with facility policy and State law) and thoroughly investigated for two (2) of two (2) allegations reviewed. Resident identifiers: #100 and #34. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was not turned for two (2) days. The family member stated that, on 09/18/10 and 09/19/10, family sat with the resident and noted no staff members coming into the room to turn the resident. The family member stated that a turning schedule posted on the inside of the closet door was left blank for both dates when reviewed on 09/20/10. The family member stated she reported the failure to turn the resident to the licensed practical nurse (LPN - Employee #9) on the morning of 09/20/10. Review of the medical record found Resident #100 was admitted to the facility on [DATE] with three (3) Stage II wounds and one (1) unstageable wound to her coccyx. The facility instituted treatment to the areas which required debridement and resulted in one (1) Stage IV wound. Review of the care plan in effect during this time period found the resident was to be assisted to turn and reposition every two (2) hours and as needed. Review of facility policy titled ""1.0 Abuse Prohibition"" found that all allegations were to be reported to the supervisor immediately. An interview with Employee #9, on 11/12/10 at 1:00 p.m., confirmed the family member reported to this nurse that her mother had not been turned for two (2) days. The nurse could provide no evidence this allegation of neglect had been reported to supervisory staff in accordance with facility policy, nor was there any evidence to reflect this allegation of neglect was immediately reported to State agencies as required by law. An interview with the administrator (Employee #65), on the afternoon of 11/12/10, revealed he was unaware any allegations had been made that Resident #100 had not been turned. He agreed this should have been reported and investigated. - b) Resident #34 Review of personnel files, on 11/12/10 at 2:50 p.m., found a corrective action notice issued to Employee #51 (a nursing assistant) dated 04/27/10. Employee #51 was assigned to care for Resident #34, and the notice documented, ""Resident... /c (with) wet, soiled brief saturated thru (sic) draw sheet & sheet. Resident stated 'I wished could walk so I didn't have to stay wet.' Bedpan discarded in trash can on tx (treatment) cart."" Review of documentation of allegations of abuse / neglect that were self-reported to State agencies found no evidence this neglect of Resident #34 (by Employee #51 ) had been reported to State agencies as required. The administrator agreed this allegation of neglect should have been reported. .",2014-07-01
11187,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-11-12,241,E,1,0,OP3T11,". Based on observation, resident interview, and staff interview, the facility failed to ensure thirteen (13) of twenty-five (25) residents were treated with dignity and respect during the dining experience. Residents who were independent with eating were kept waiting up to forty (40) minutes to be served, until the residents who required staff assistance were finished eating. Resident identifiers: #17, #13, #40, #45, #17, #21, #23, #39, #35, #28, #7, #38, and #59. Facility census: 62. Findings include: a) Residents #17, #13, #40, #45, #17, #21, #23, #39, #35, #28, #7, #38, and #59 Random observations of the dining room, during the noon meal at 12:30 p.m. on 11/12/10, found residents being assisted from the dining room. Upon entrance to the dining room, observation found residents who required assistance with eating were finishing their meals while the tables of residents who were independent with eating had not been served their meals. Further observation noted thirteen (13) residents were seated at the tables and waiting for their meals. Interviews with these residents found that ten (10) of the thirteen (13) residents expressed being hungry. Resident #40 stated he was hungry before he came into the dining room and had been waiting forty (40) minutes for his meal. He expressed it was always this way and he did not like to have to wait. An interview with the activities director (Employee #87), who was present in the dining room, revealed the independent residents' meal trays were served last. .",2014-07-01
11188,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-11-12,314,D,1,0,OP3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, resident interview, staff interview, review of manufacturer's information for the Stat 4000 air mattress, and medical record review, the facility failed to provide care and services to promote healing of pressure ulcers for two (2) of four (4) sampled residents. Resident identifiers: #100 and #18. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was not turned for two (2) days. The family member stated that, on 09/18/10 and 09/19/10, family sat with the resident and noted no staff members coming into the room to turn the resident. The family member stated that a turning schedule posted on the inside of the closet door was left blank for both dates when reviewed on 09/20/10. The family member stated she reported the failure to turn the resident to the licensed practical nurse (LPN - Employee #9) on the morning of 09/20/10. Review of the medical record found Resident #100 was admitted to the facility on [DATE] with three (3) Stage II wounds and one (1) unstageable wound to her coccyx. The facility instituted treatment to the areas which required debridement and resulted in one (1) Stage IV wound. An interview with Employee #9, on 11/12/10 at 1:00 p.m., revealed Resident #100 was to be turned every two (2) hours for treatment of [REDACTED]. She confirmed the family member reported to her that the resident had not been turned for two (2) days. She further stated she viewed the turning schedule with the family member, and two (2) days had been left blank. Review of the medical record found the care plan instructed staff members to turn and reposition the resident every two (2) hours. -- b) Resident #18 An interview with the resident, on 11/10/10 at 5:30 p.m., revealed staff was not turning her since she got her new bed. The resident stated she was told that the new bed took care of it. Interviews with the assigned LPN (Employee #35) and nursing assistant (Employee #52), on the afternoon of 11/11/10, revealed it was their understanding that residents on ""air mattresses"" did not have to be turned as often as residents on regular beds. Review of the medical record found the resident had a Stage IV wound on her coccyx. The care plan instructed staff to turn and reposition the resident every two (2) hours and as needed. An interview with the wound nurse (Employee #9) and the administrator (Employee #65), on the afternoon of 11/12/10, revealed the representative who rented them the bed stated that residents did not have to be turned with this new system. When asked to be shown the manufacturer's information to determine the accuracy of this claim, the facility was unable to provide the information from the manufacturer. The administrator contacted the representative and had a copy of the manufacturer's information faxed to the facility. Review of this faxed information found no statements that residents utilizing this mattress did not require to be turned and repositioned. Section 2 entitled ""Positioning the Patient"" stated, ""The STAT 4000's unique air flotation features make it easier for the caregiver to turn and position a patient... To reposition the patient..."". .",2014-07-01
11189,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-11-12,514,D,1,0,OP3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, staff interview, and medical record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one (1) of four (4) records reviewed. Resident identifier: #100. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was to be turned every two (2) hours for treatment of [REDACTED]. The family member stated the facility maintained a turning schedule on the inside of the closet door on which staff was to document when they had turned the resident. Review of the medical record found no turning schedule. An interview with the wound care nurse (Employee #9), on 11/12/10 at 1:00 p.m., revealed a turning schedule had been posted in the resident's closet. The facility was unable to locate the turning schedule in the medical record. .",2014-07-01
11190,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-03-11,241,D,1,0,V0RD11,". Based on random observation and staff interview, the facility failed to ensure care was provided in a manner that maintained dignity and respect for one (1) of seven (7) sampled residents, when a nursing assistant did not provide the resident with assistance to the bathroom when asked. Resident identifier: #64. Facility census: 63. Findings include: a) Resident #64 Random observations, on 03/09/10 at 3:30 p.m., found Resident #64 seated in his wheelchair outside the restroom on the service hallway adjacent to the nursing station. A nursing assistant (NA - Employee #50) was present in the restroom. Resident #64 was overheard to ask Employee #50 to help him to the bathroom. Employee #50 stated, ""I can't. I'll have to get your aide. I'm getting ready to give a shower."" The resident continued to sit outside the bathroom. The administrator (Employee #68) approached the resident and asked him how he was doing. The resident stated, ""Fine, if I could get to a bathroom."" The administrator assisted the resident into the restroom and indicated to Employee #50 that the resident needed to go to the bathroom. The resident stated, ""She said she couldn't help me."" The administrator agreed Employee #50 should have assisted Resident #64 to the bathroom when asked. .",2014-07-01
11191,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-03-11,253,E,1,0,V0RD11,". Based on observation and staff interview, the facility failed to provide housekeeping services to maintain a sanitary interior. This deficient practice was found for two (2) of two (2) observations of housekeeping services in resident rooms. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Employee identifiers: #59 and #44. Facility census: 63. Findings include: a) Employee #59 An observation of housekeeping services was conducted on 03/07/10 at 10:10 a.m., related to a review of infection control practices within the facility. Employee #59 was observed while cleaning the room of a resident with a history of Vancomycin-resistant Enterococcus (VRE) in the urine. Employee #59 used her gloved hands to remove a rag from a bucket which contained approximately 1/2 inch of sanitizing solution (cleaning rags should be submerged beneath the sanitizing solution), along with a caddy containing toilet bowl cleaner and a toilet mop. She then squirted toilet bowl cleaner into the toilet bowl and utilized the rag to clean the outside of the toilet, including the toilet seat. She then utilized the toilet mop to clean the inside of the toilet bowl. After cleaning the toilet bowl, Employee #59 squeezed the excess liquid from the toilet mop with her gloved right hand. She then touched the doorknob on the inside and outside of the bathroom door and the inside doorknob on hallway door while returning the caddy to her cart. Without changing her gloves, Employee #59 dusted the room. She touched stuffed animals, personal items, bedrails, bed controls, bed curtains, bedside tables, and wheelchair arms with her contaminated gloves. Following the cleaning of the room, Employee #59 was interviewed. She was asked how often the toilet mop was changed. She stated she had been back to work since 01/09/10 and had used this particular mop since then. She removed her gloves and, without cleansing or sanitizing her hands, she then moved to the next room to begin cleaning. b) Employee #44 Observation, on 03/07/10 at 11:20 a.m., found Employee #44 cleaning the bathroom and toilet bowl in a resident room with gloved hands. Without removing her gloves or sanitizing her hands, she returned the cleaning supplies to the housekeeping cart. She touched the outside door of the cart with her contaminated gloves. .",2014-07-01
11192,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-03-11,323,E,1,0,V0RD11,". Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as is possible. Employee #96 left Resident #58 unattended in the beauty shop with bottle of unidentified solution and with a hot curling iron resting on the counter. This deficient practice affected one (1) randomly observed resident and had the potential to affect any confused resident who may wander into open beauty shop. Resident identifier: #58. Facility census: 63. Findings include: a) Resident #58 Random observations of the facility, on 03/09/10 at 2:40 p.m., found the door to the beauty shop to be wide open with Resident #58 seated beneath a hair dryer and no staff in attendance. When asked how she was, the resident appeared unable to speak. It was also noted that her right arm was curled in an upward position with her hand closed. Further inspection noted bottles of solution and a hot curling iron present on the waist-high counter. After approximately five (5) minutes, Employee #96 entered the beauty shop. She stated she was the beautician. When asked why the resident was left alone with a hot curling iron on the counter, Employee #96 stated she had to transport another resident. The administrator (Employee #68) was informed of the above observation. .",2014-07-01
11193,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2010-03-11,441,E,1,0,V0RD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to establish and maintain an effective infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of disease and infection. Random observations of housekeeping services provided in two (2) of two (2) resident rooms (one (1) room of which was occupied by a resident with a history of [MEDICATION NAME]-resistant [MEDICATION NAME] in the urine) found opportunities for cross-contamination of the resident environment by the housekeepers. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Employee identifiers: #59 and #44. Facility census: 63. Findings include: a) Employee #59 An observation of housekeeping services was conducted on 03/07/10 at 10:10 a.m., related to a review of infection control practices within the facility. Employee #59 was observed while cleaning the room of a resident with a history of [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in the urine. Employee #59 used her gloved hands to remove a rag from a bucket which contained approximately 1/2 inch of sanitizing solution (cleaning rags should be submerged beneath the sanitizing solution), along with a caddy containing toilet bowl cleaner and a toilet mop. She then squirted toilet bowl cleaner into the toilet bowl and utilized the rag to clean the outside of the toilet, including the toilet seat. She then utilized the toilet mop to clean the inside of the toilet bowl. After cleaning the toilet bowl, Employee #59 squeezed the excess liquid from the toilet mop with her gloved right hand. She then touched the doorknob on the inside and outside of the bathroom door and the inside doorknob on hallway door while returning the caddy to her cart. Without changing her gloves, Employee #59 dusted the room. She touched stuffed animals, personal items, bed rails, bed controls, bed curtains, bedside tables, and wheelchair arms with her contaminated gloves. Following the cleaning of the room, Employee #59 was interviewed. She was asked how often the toilet mop was changed. She stated she had been back to work since 01/09/10 and had used this particular mop since then. She removed her gloves and, without cleansing or sanitizing her hands, she then moved to the next room to begin cleaning. b) Employee #44 Observation, on 03/07/10 at 11:20 a.m., found Employee #44 cleaning the bathroom and toilet bowl in a resident room with gloved hands. Without removing her gloves or sanitizing her hands, she returned the cleaning supplies to the housekeeping cart. She touched the outside door of the cart with her contaminated gloves.",2014-07-01
11194,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,225,D,1,0,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of self-reported allegations of abuse / neglect, and staff interview, the facility failed to immediately report to all applicable State officials, as required by law, all nurse aides who were identified by the facility as having failed to provide goods and services to avoid physical harm to one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute [MEDICAL CONDITION] with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Three (3) nurse aides were identified, through the facility's internal investigation into cause of the fracture, as having transferred Resident #147 manually on 09/02/10; however, the facility only reported two (2) of the three (3) aides to the State's Nurse Aide Program (NAP) for neglect. Employee identifiers: #141, #152, and #170. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and [MEDICAL CONDITION]. The assessor did not identify, as active diagnoses, either [MEDICAL CONDITION] or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): ""ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia."" Goals associated with this problem statement were: ""Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning."" Interventions to meet these goals included: ""Tranfer (sic) with 2 person / Mechanical Lift (sic)."" (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - ""Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') [MEDICAL CONDITION], (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station."" The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it ""error"", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - ""C/O (complaint of) pain in left leg. PRN (as needed) [MEDICATION NAME] x 1 per order /c (with) No (sic) relief."" - 09/03/10 at 2:30 a.m. - ""Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..."" - 09/03/10 at 3:15 a.m. - ""Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)."" The resident did not return to the facility after her discharge from the hospital. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a ""date of exam"" of ""2010-09-02"" (09/02/10) contained the following impression: ""Left tibia-fibula - Mildly displaced acute [MEDICAL CONDITION] fibular shaft and fibular head demonstrated."" There was no evidence to reflect this acute displaced [MEDICAL CONDITION] fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of [MEDICAL CONDITION] or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility initially reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: ""Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..."" The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be ""Unknown"". - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: ""During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: ""'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' ""'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. ""We didn't use a gait belt; we didn't use a mechanical lift. ""'I did not check the Patient information worksheet.' ""'I know we are a no lift company.' ""'I have used the lift in the past.' ..."" -- 5. Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) manually transferred the resident on 09/02/10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. Upon completion of the internal investigation, the facility subsequently reported to the NAP only two (2) of the three (3) nurse aides (Employees #152 and #141) who were found to have manually transferred Resident #147 contrary to her assessment and care plan, which constituted a failure to provide goods and services necessary to avoid physical harm (neglect). There was no evidence to reflect the facility reported Employee #170 to the NAP for resident neglect. -- The assistant director of nursing (ADON - Employee #139) confirmed the facility had not reported Employee #170 when the other two (2) nurse aides were reported to the NAP for neglect. She had no comment regarding why Employee #170 was not reported. She reported that Employee #170 was suspended on 09/08/10 and elected not to return to work. .",2014-07-01
11195,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-03-17,246,D,1,0,JBHR11,". Based on observation, resident interview and staff interview, the facility failed to ensure call lights were accessible / available for use for three (3) of twenty (20) sampled residents. Resident identifiers: #73, #39, and #43. Facility census: 146. Findings include: a) Resident #73 During observations of the second floor on 03/09/11 at 9:40 a.m., Resident #73 was noted to be calling out for help. Upon entering the resident's room, Resident #73 asked, ""How do I notify someone I need help?"" The resident then stated, ""I'm in pain and don't feel well, and I need someone."" When asked where her call light was, the resident stated, ""I don't know. I have not seen it."" Observation found the call light was under the head of resident's bed and against the wall. This surveyor alerted the director of care delivery (DCD - Employee #120) of Resident #73's request for assistance and that the resident's call light was on the floor under her bed. The DCD entered the resident's room and retrieved the call light for her. During an interview on 03/09/11 at 9:45 a.m., Employee #120 confirmed Resident #73's call light was not available for use and should have been placed within the resident's reach. -- b) Resident #39 During an interview on 03/09/11 at approximately 9:55 a.m., Resident #39 stated she had wanted to get out of bed but was unable to do so, because she ""could not get anyone's attention."" She stated she could not reach her call light. Observation found her call light was clipped to the bed sheets at the top left hand side of the bed above the resident's head. A nursing assistant (Employee #65) was summoned to the resident's room by the surveyor at approximately 9:55 a.m. on 03/09/11. This employee did assist the resident with getting out of bed into her wheelchair. -- c) Resident #43 On 03/09/11 at approximately 3:15 p.m., observation found Resident #43's call light on the floor beside the resident's bed. The DCD (Employee #105) was summoned to the resident's room by the surveyor shortly after this observation was made, and the DCD placed the call light back on the resident's bed and within the resident's reach. .",2014-07-01
11196,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-03-17,225,D,1,0,JBHR11,". Based on review of the facility's resident concern forms and staff interview, the facility failed to report to State agencies an allegation of neglect. This was true for one (1) of five (5) resident concern forms reviewed. Resident identifier: 148. Facility census: 147. Findings include: a) Resident #148 Review, on 03/09/11, of the facility's resident concern forms for the past month revealed a concern form completed on behalf of Resident #148, dated 02/25/11, stating, ""Pt. (patient) states that staff is not getting her cleaned up, do not give her her clothes, do not answer call light."" When interviewed at 5:00 p.m. on 03/09/11, the director of care delivery (DCD - Employee #105) and the administrator (Employee #55) stated these allegations of neglect had been investigated but were not reported to State agencies. .",2014-07-01
11197,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-03-17,356,C,1,0,JBHR11,". Based on observation and staff interview, the facility failed to post the nurse staffing data as required by the regulations. This practice had the potential to affect all residents / visitors at this facility wishing to view the staffing information. Facility census: 146. Findings include: a) On 3/8/11 at 10:30 p.m., the facility was entered to conduct a complaint investigation. The nurse staffing data were unable to be located for 03/08/11. When interviewed at approximately 11:15 p.m. on 03/08/11, the director of nursing (DON - Employee #13) stated the posting was on the door leading into her office. When the surveyor observed the posting with the DON, the posting was dated 03/07/11. The DON verified that a posting had not been completed for 03/08/11. .",2014-07-01
11198,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-06-01,323,G,1,0,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to provide an environment as free as possible of accident hazards and failed to ensure each resident received interventions as planned to prevent avoidable accidents with injuries for one (1) of thirty-three (33) Stage II sample residents. Resident #48 fell from her bed at 3:05 a.m. on 05/23/10. At the time of the fall, the resident's bed was not in the lowest position as per her physician's orders [REDACTED].) As a result of the fall, the resident sustained [REDACTED]. The facility also failed to fully investigate the circumstances around the fall as evidenced by a failure by staff to complete the facility's ""Resident Fall Investigation Form"" for this incident. Resident identifier: #48. Facility census: 57. Findings include: a) Resident #48 1. Review of Resident #48's comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/18/09, revealed this [AGE] year old was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She transferred to the hospital on [DATE] and returned to the facility on [DATE]. According to the most recent quarterly assessment with an ARD of 03/22/10, she had problems with both short and long term memory; was not oriented to person, place or time; had moderately impaired cognitive skilled for daily decision making; required extensive assistance with bed mobility; was totally dependent with transferring between surfaces (e.g., bed to chair); and had partial loss of voluntary movement on one (1) side of her body. Further record review revealed Resident #48 fell from her bed at 3:05 a.m. on 05/23/10. 2. The incident report related to this fall, when reviewed on 05/28/10, contained the following: - Under ""Description of incident"" - ""Resident found lying on (R) right side on floor beside bed."" - Under ""Description of injury"" - ""Bruises to bilateral knees and (R) shoulder."" The report was signed by a licensed practical nurse (LPN - Employee #43) on 05/23/10 at 3:30 a.m., by the assistant director of nursing (ADON - Employee #67) on 05/24/10, and by the administrator (Employee #63) on 05/25/10. Attached to the incident report was found a two-page form entitled ""Resident Fall Investigation Form"". Under Section 1, ""Fall Risk Status"", in response to the question ""What preventive measures are on the care plan?"", staff documented, ""Low bed when unattended."" The section titled ""New interventions / preventive measures added to care plan:"" was blank, as was the section titled ""Signature of person completing Section 1"". Review of Section 2 ""Unavoidable status"" found this was to be completed by the interdisciplinary team (IDT) within seventy-two (72) hours of a fall. Review of Part A titled ""A determination that a fall was unavoidable may be made only if routine preventive care is provided including (check if documentation verifies):"" found the following items were left blank: - ""Care Plan followed?"" - ""Supervision done as established?"" - ""Therapy Recommendations followed?"" - ""Were new interventions implemented (from Section 1)?"" - ""Additional team recommendations?"" - ""Care plan updated?"" - ""Staff aware?"" Section 2 was signed by the clinical records coordinator (Employee #65), the assistant rehabilitation program manager (Employee #69), the social services director (Employee #68), and the director of admissions (Employee #57) on 05/24/10. Review of Section 3 ""Follow-up to be completed by DON (director of nursing) / designee within five (5) working days of fall"" found the following items were left blank: - ""Was the resident seen by the interdisciplinary team within 72 hours?"" - ""What new interventions were implemented"" - ""Was the care plan updated to reflect the changes?"" - ""DON signature:"" Section 3 was signed by the administrator (Employee #63) on 05/25/10. 3. A review, on 05/27/10, of the care plan in effect for Resident #48 (dated 03/22/10) revealed a focus area of: ""Resident is at risk for falls: CVA (cerebrovascular accident) with right hemiparesis and anti-depressant meds."" The goals associated with this problem statement were: ""Resident will have no falls with injury and will not exhibit any adverse reactions r/t (related to) meds through next review date."" The first intervention listed to accomplish the goals was: ""Utilize low bed."" 4. A review, on 05/27/10, of physician's orders [REDACTED]."" Another order (dated 05/24/10 - the day after the fall) stated, ""X-ray (L) (left) knee in a.m. (morning) knee pain /c (with) recent fall."" (A subsequent review of the medical record, on 05/31/10 at 11:09 a.m., revealed the x-ray was done on 05/25/10 for pain in the left knee from the fall.) When interviewed on 05/27/10 at 9:00 a.m., the sons of Resident #48 stated they both had been informed by facility staff that Resident #48's bed was not in the low position at the time of the fall on 05/23/10. In an interview with the nurse who responded to the fall in Resident #48's room on 05/23/10 (Employee #43), on 05/31/10 at 6:35 a.m., Employee #43 stated that, during the early morning hours of 05/23/10, he responded to Resident #48's room immediately after her fall. He assessed the resident, discovered bruises to both knees and her right shoulder, and assisted her back into bed. When asked if the bed was in the low position prior to the fall, he stated, ""No."" He clarified that the bed was not up ""all the way"", but it was not in the low position as ordered. He stated he thought there was some confusion regarding the physician's orders [REDACTED]. An interview was conducted with nursing assistant (Employee #31) at 6:50 a.m. on 05/31/10; she was the nursing assistant who initially went into the room and found Resident #48 on the floor. Employee #31 stated she heard the resident yelling out and went to the room to see what had happened. She found the resident lying on floor and alerted a nurse, who sent Employee #43 into the room. When asked about the position of the bed, she, at first, said she could not recall, but then she said she thought it would have been down (in the low position). The administrator, when interviewed on 05/31/10 at 10:00 a.m., was asked if the bed was in low position. She reported she did not know that information and would have to ask the nursing assistant who responded to the fall. In a follow-up interview conducted with the son of Resident #48 at 9:16 .m. on 06/01/10, he stated that, when he was notified of the fall, he specifically asked Employee #43 what the position of the bed was at the time of the fall, and Employee #43 told him the bed was not in the low position. .",2014-07-01
11199,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,156,C,1,0,7YYR11,". Based on observation, review of the facility's procedure for filing complaints, and staff interview, the facility failed to post the correct mailing address for contacting the State survey and certification agency and failed to provide clear and concise information to residents and the public on how to file a complaint with that agency. This practice had any residents, legal representative, or member of the general public wishing to file a complaint with the State. Facility census: 61. Findings include: a) The bulletin board posting in the front lobby of the facility gave an incorrect mailing address listed for the Office of Health Facility Licensure and Certification (OHFLAC - the State survey and certification agency). b) The same bulletin board also contained a posting of how to file complaints. This was a facility-originated form informing residents / legal representatives of the steps to follow if they wanted to report complaints. The information was unclear as to how to make a formal complaint to OHFLAC when an individual believed this action was necessary. c) In an interview with the administrator (Employee #59) and the director of nursing (DON - Employee #54) at 12:30 p.m. on 05/19/10, both agreed the posted address for OHFLAC was incorrect. Both employees also agreed the posted form for making in-house complaints did not clearly address who to contact at the State level to file a complaint. .",2014-07-01
11200,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,157,E,1,0,7YYR11,". Based on medical record review, review of incident / accident reports, and staff interview, the facility failed to notify the legal representative immediately following an incident / accident. This practice affected four (4) of twenty-seven (27) sampled residents. Resident identifier: #15, #50, #57, and #60. Facility census: 61. Findings include: a) Residents #15, #50, #57, and #60 The previous three (3) months of facility incident / accident reports were reviewed at 11:30 a.m. on 05/18/10. Reports involving four (4) residents (#15, #50, #57, and #60) were observed to lack evidence of notification of the legal representative following an incident / accident. Review of these residents' medical records also did not find documentation to reflect their legal representatives had been informed. In an interview with the administrator (Employee #59) and the director of nursing (DON - Employee #54) at 12:30 p.m. on 05/19/10, both employees agreed there was no documentation to reflect the legal representatives of Residents #15, #50, #57, and #60 had been contacted following the incidents referenced above. .",2014-07-01
11201,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,279,D,1,0,7YYR12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and facility policy review, the facility failed, for one (1) of ten (10) sampled residents reviewed, to develop an interdisciplinary care plan for a resident with dysphagia who was identified as being at high risk of altered nutrition and who was receiving rehabilitative therapy services to promote improved nutritional intake. Resident identifier: #3. Facility census: 54. Findings include: a) Resident #3 1. Medical record review, on 08/04/10, revealed Resident #3 was admitted to the facility on [DATE]. On 10/28/08, the facility first identified she was at risk for decreased nutritional intake. On 06/10/10, she exhibited swallowing difficulties; the speech-language pathologist (SLP) assessed her and identified she needed a mechanical soft diet with ground meats. Resident #3 began receiving speech therapy (ST) and occupational therapy (OT) to address her decreased nutritional intake and promote self-feeding. Review of Resident #3's weight records revealed she weighed 194# on 05/19/10, weighed 188# on 06/09/10, and weighed 186# on 07/12/10. This represented an 8# weight loss in two (2) months. - 2. Review of the OT progress notes found the following entries: On 06/15/10 - ""Pt (patient) seen for lunch meal, removed distracting items like butter knife and food ticket and pushed resident closer to table. Pt also sitting at same table but on opposite side away from distractions of dining room."" On 06/16/10 - ""Pt seen for lunch meal, provided a bright red place mat to define eating space, removed distracting items."" On 06/17/10 - ""Pt seen for breakfast meal, removed distracting items and cued patient to initiate meal (sic) pt complies. Discussed / educated present CNA (certified nursing assistant) staff on approaching patient, cueing patient and items to remove. Inservice completed to kitchen staff (servers, etc.) regarding patient (approaching patient, set-up of table, etc)."" - 3. Review of the ST progress notes found not all of the notes had been filed in the resident's clinical record. Review of these notes, after being produced upon request, found the following: On 06/08/10 - ""Educated staff regarding importance of providing mechanical soft items. Pt requiring cues to cont(inue) consumption, i.e. placing utensil in hand, preparing bite and verbally cueing pt to take bite."" On 06/16/10, recorded in the Assessment Summary / Summary of Progress - ""Staff educated regarding decreasing distractions during meals and appropriate cueing to facilitate intake, as well as strategies to improve communication via using positive facial expressions to redirect, and allowing breaks between attempts to decrease agitation."" On 06/22/10 - ""Upon entering dining room, despite reviewing strategies to facilitate self-feeding, CNA found to be feeding the pt. Pt with increased distractions in line of vision. CNA educated to remove unnecessary items, to place plate within pt's view, decrease distractions in area (cue patient from side), place utensils in hand, verbally cue to take bite."" - 4. Review of the resident's current care plan, with an initiated date of 10/28/08, a revision date of 06/07/10, and a target date of 08/16/10, found no mention of these resident-specific interventions utilized by OT or the SLP to reduce meal-time distractions and promote increased food consumption. - 5. According to a facility policy and procedure titled ""10.10 Nutrition / Hydration Management"" (with a revision date of 06/01/09), on page 3 was: ""7. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration. Include: ""7.1 Dietician or speech and language pathologist (SLP) recommendations as indicated.""",2014-07-01
11202,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,323,G,1,0,7YYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of sixteen (16) sampled residents, to provide adequate supervision and/or assistive devices to prevent an accident with injury. Resident #6 had a [DIAGNOSES REDACTED]. A physical therapy evaluation identified her as being at risk for falling, and staff was aware of her tendency to lean forward in her wheelchair. The only interventions implemented to promote her safety related to falling was staff encouraging and reminding her to sit back in her wheelchair, directives which she was not able to remember and consistently perform on her own due to her impaired cognition. On the afternoon of 04/25/10, Resident #6 fell face first from her wheelchair and sustained a fractured nose. Resident identifiers: #6. Facility census: 61. Findings include: a) Resident #6 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE], for rehabilitation for debility, [DIAGNOSES REDACTED] (LBD), and resolved pneumonia and urinary tract infection. Other [DIAGNOSES REDACTED]. 2. According to information from the Alzheimer's Association (found via the Internet at ): ""Dementia with Lewy bodies is characterized by abnormal deposits of a protein called alpha-synuclein that form inside the brain's nerve cells. ... ""Symptoms of dementia with Lewy bodies (include) - Memory problems, poor judgment, confusion and other cognitive symptoms that overlap with Alzheimer's disease. - Excessive daytime drowsiness. - Visual hallucinations. - Cognitive symptoms and level of alertness may get better or worse (fluctuate) during the day or from one day to another. - Movement symptoms, including stiffness, shuffling walk, shakiness, lack of facial expression, and problems with balance and falls. ..."" 3. Review of the resident's admission care plan, dated 04/21/10, noted the resident was exhibiting symptoms of decline in her cognitive function related to the LBD. Interventions were not individualized in relation to the resident, with only broad approaches listed. 4. Review of the physical therapy treatment encounter note, dated 04/22/10, identified the need for precautions related to fall risk. Following this initial evaluation, the facility failed to develop a care plan to address her fall risk with interventions appropriate to her level of cognitive functioning, in order to promote safety and prevent falls with injuries. 5. Documentation in the resident's medical record indicated staff was aware of resident's tendency to lean forward in her wheelchair. The resident had an order for [REDACTED]. Physical therapy notes, dated 04/23/10, stated, ""Patient continually leans forward in chair and tries to stand without assistance."" Nursing documentation, on 04/23/10 at 2:46 p.m., stated the resident was ""frequently encouraged to sit back in wheelchair to prevent possibility of fall. Resident continually leaning forward in wheelchair, unable to redirect."" 6. On 04/25/10 at 1:30 p.m., documentation in the resident's medical record noted, ""Resident was sitting in the wheelchair within the Madison Canter TV lounge. Resident attempted to stand up without assistance and fell to the floor and suffered a laceration on bridge of nose. Resident sent to the hospital; hospital states nose is broken."" Further review of the medical record revealed a nursing progress note, dated 04/25/10 at 14:46 (2:46 p.m.), stating, ""Resident was in wheelchair in TV lounge at nurses station. Frequently encouraged to sit back in the wheelchair to prevent possibility of fall. Resident continually leaning forward in wheelchair, unable to redirect. Resident fell face first onto the floor from wheelchair. Laceration noted to bridge of nose with swelling. Resident daughter and doctor notified will transport to (acute care hospital) for eval(uation)."" Documentation of the facility ' s investigation into this fall stated, ""Resident fell from wheelchair due to her continually leaning forward. Resident was instructed by staff to sit back however due to [DIAGNOSES REDACTED] resident unable to comprehend this. Fall did result in laceration to bridge of nose and bilateral black eyes."" 7. On 05/19/10 at 2:00 p.m., the facility's administrator (Employee #59), the regional speech language pathologist (SLP - Employee #65), the director of nursing (DON - Employee #54), and the assistant director of nursing (ADON - Employee #63) were interviewed. The members of this care management team acknowledged the resident's comprehensive plan of care did not include appropriate interventions to prevent falls from the wheelchair and that she was redirected and encouraged to sit back in the chair per staff, directives which were beyond her cognitive ability to understand and consistently follow to promote safety and prevent falls. .",2014-07-01
11203,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-02-24,323,E,1,0,D7CV11,". Based on observation and staff interview, the facility failed to secure the treatment cart (which contained potentially hazardous items) against unauthorized access by residents. This had the potential to affect any residents residing on the unit who may wander and gain access to the treatment cart. Facility census: 52. Findings include: a) Observation of 300 hallway, at 3:15 p.m. on 02/22/10, found the treatment cart to be unlocked, unattended, and out of the line of sight of the treatment nurse. In an interview with the treatment nurse (Employee #51), she agreed the treatment cart should be locked but reported the lock was broken. In an interview at 3:25 p.m. on 2/22/10, the director of nursing (Employee #53) agreed the treatment cart should be locked at all times when left unattended.",2014-07-01
11204,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-02-24,309,D,1,0,D7CV11,". Based on record review and staff interview, the facility failed to adequately monitor residents on an ongoing basis to promptly identify and treat acute changes in condition related to constipation and fluid volume deficit. This was found for three (3) of eight (8) sampled residents whose records were reviewed. Resident identifiers: #14, #37, and #21. Facility census: 52. Findings include: a) Resident #14 Review of Resident #14's medical record, on 02/23/10, found concerns in the areas of monitoring and assessment of bowel elimination. Entires recorded on the two (2) primary sources of documentation of daily bowel elimination for Resident #14 were found to be in conflict. The forms used by nursing assistants (NAs) to record a resident's bowel movements (titled ""ADL (Activities of Daily Living) Flow Sheet"") and the forms used by licensed nurses to record a resident's bowel movements (titled ""Medication Administration Record"" (MAR)) contained many contradictory entries. For example, entries on December 2009 ADL Flow Sheet indicated Resident #14 had only three (3) bowel movements (BMs) throughout the entire month - on 12/02/09, 12/04/09, and 12/11/09. Entries on the December 2009 MAR indicated [REDACTED]. When interviewed on 02/23/10 at 10:00 a.m., the facility's director of nursing (DON - Employee #53) and assistant director of nursing (ADON - Employee #62) confirmed these discrepancies. They stated the nurses rely upon the nursing assistants for the data they enter on the MARs, which is then relied upon as the basis for initiating treatment for constipation. Such discrepancies could result in inaccurate assessments related to the resident's ongoing bowel elimination pattern and unnecessary treatment or lack of appropriate treatment for constipation. b) Resident #37 The medical record of Resident #37, when reviewed at 9:30 a.m. on 02/23/10, disclosed documentation on the January 2010 ADL Flow Record indicating the resident had only seven (7) BMs during that month - two (2) on 01/01/10, and one (1) each on 01/07/10, 01/19/10, 01/20/10, 01/23/01, and 01/26/10. Further review of the medical record found, during the month of December 2009, the resident only had two (2) documented BMs - on 12/01/09 and 12/08/09. The facility's bowel protocol was to be automatically initiated once a resident had not had a BM for a period of three (3) consecutive days, and this protocol was not initiated for Resident #37. In an interview with the treatment nurse (Employee #56) on 02/23/10 at 11:00 a.m., she agreed the documentation reflected Resident #37 had only seven (7) BMs in January 2010 and only two (2) BMs in December 2009 and the bowel protocol had not been initiated during either month when the records indicated the resident had no BM for three (3) consecutive days. The treatment nurse stated the licensed nurses rely upon the nursing assistants for the data they enter daily in regards to BMs. This information is then relied upon as the basis for assessment and treatment of the resident. In an interview at 3:15 p.m. on 02/23/10, the DON reported nursing staff was not accurately recording the resident's BMs. When the ADL Flow Record documentation was compared to the licensed nurses' documentation, there were several discrepancies in the number of BMs recorded each month. Also during this interview, the administrator (Employee #58) and the DON agreed there were several days without documentation to indicate a BM had occurred. Such discrepancies could result in inaccurate assessments related to the resident's ongoing bowel elimination pattern and unnecessary treatment or lack of appropriate treatment for constipation. c) Resident #21 The medical record of Resident #21, when reviewed at 1:00 p.m. on 02/22/10, revealed the resident received nutrition via a gastrostomy tube and staff was to monitor and record the resident's fluid intake and output (I&O) daily on each shift. Review of the resident's I&O records found multiple days on which fluid intake and/or output were omitted. From the time period of 12/12/09 through 02/22/10 (excluding the days he was hospitalized ), there were one hundred and seventy-one (171) shifts that lacked intake documentation and one hundred (100) shifts that lacked output documentation. In an interview with the DON and administrator, both agreed there were multiple omissions. Although the resident's lab values were within normal limits, such omissions could result in inaccurate assessments related to the resident's ongoing hydration needs and unnecessary treatment or lack of appropriate treatment for fluid volume deficits. .",2014-07-01
11205,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,161,E,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a surety bond to assure the security of all personal funds deposited with the facility; the current surety bond expired on [DATE]. This has the potential to affect all forty-five (45) residents for whom the facility currently handles personal funds. Facility census: 116. Findings include: a) A review of the facility's current surety bond found it had expired on [DATE]. The survey began on [DATE]. There was no evidence that a certificate of continuation had been submitted to the State survey agency or approved by the State attorney general's office as required by State law. Discussion with the administrator, on the afternoon of [DATE], confirmed the surety bond had not been renewed as of this date. The facility handles the personal funds of forty-five (45) current residents. .",2014-07-01
11206,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,492,C,0,1,TDS111,"Based on record review and staff interview, the facility staff failed to accurately complete the forms CMS-672 and CMS-802 as part of the survey process. These two (2) documents, which were computer-generated based on data entered by staff into the resident assessment instruments, were found to contain conflicting information concerning the residents' care needs. This was found to be a systems problem and had the potential to affect all residents for whom minimum data set (MDS) assessments had been completed. Facility census: 116 Findings include: a) Review of the facility-generated form CMS-802 (Resident Roster) revealed care areas that were identified on this form as problems for the residents did not also appear on the form CMS-672 (Resident Census and Conditions of Residents). As the information on both forms was to pull from the same data entered by staff into the residents' MDS assessments, these data should not be in conflict with each other. Example: According to the CMS-802, two (2) residents were receiving hospice services. According to the CMS-672, five (5) residents were receiving hospice services. When the administrator brought a handwritten list of names of persons receiving hospice, it contained six (6) residents. Discussion with the MDS coordinator (Employee #22), the director of nursing, corporate staff, and the administrator, at different times throughout the survey, revealed the unit managers were to enter MDS information into the computer and update that information as needed. The nurses and MDS coordinator then were to enter the final totals into the CMS-672. Unit managers were not updating the MDS and the CMS-672 at the same time. One was being updated but not the other, which resulted in the different totals. This was found to be a systems problem, and corporate staff indicated it would be corrected with inservicing and additional training. .",2014-07-01
11207,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,279,D,0,1,TDS111,"Based on care plan review and staff interview, the facility failed to develop, for one (1) of twenty-one (21) residents, a care plan that adequately addressed all problems / needs identified by staff. Resident identifier: #59. Facility census: 116. Findings include: a) Resident #16 Record review, on 12/01/09 at approximately 9:00 a.m., revealed Resident #16 exhibited verbally and physically aggressive behaviors. Aggressive behavior was noted on 10/14/09. On 10/30/09, staff documented the resident was cursing and agitated. On 11/21/09, staff documented the resident was hitting and kicking staff. On 11/25/09, Resident #16 was continuously hitting staff and cursing; redirection was not successful. Further record review found the care plan for Resident #16 did not address the resident's physically and verbally aggressive behaviors. On 12/01/09 at approximately 11:00 a.m., the assistant director of nursing (ADON) presented a copy of a revised care plan which included the problem of aggressive behaviors. She agreed this issue should not have been left out of the resident's previous care plan. .",2014-07-01
11208,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,502,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure laboratory tests were completed in a timely manner and/or in accordance with physician orders [REDACTED]. Resident identifiers: #57 and #32. Facility census: 116. Findings include: a) Resident #57 Medical record review for Resident #57, conducted on 12/02/09 at approximately 1:00 p.m., revealed a physician's orders [REDACTED]. A nurse's note, dated 11/25/09, indicated the resident had displayed violent behaviors that day. The physician had ordered [MEDICATION NAME] 0.5 mg every six (6) hours for seven (7) days and also ordered a urinalyses with C&S. There was no evidence to reflect these lab tests were completed as ordered. In an interview, Employee #91, a licensed practical nurse (LPN), related she had telephoned the physician on 12/02/09 after 1:00 p.m., at which time he stated he no longer wished for the tests to be completed. The tests were ordered on [DATE], and seven (7) days had passed without any notice by the facility that they had not been completed. b) Resident #32 Review of Resident #32's medical record revealed the physician ordered a urinalysis and C&S via catheterization on 10/21/09, due to the resident's increased confusion and painful urination. Review of a nurse's notes, dated 10/21/09, revealed evidence this resident was hearing and seeing things, had increased confusion, and complained of painful urination. Subsequently, the physician was notified and the new orders were received. No further notation was found in nursing notes regarding the urinalysis and C&S was documented until 10/28/09, when the lab called the facility to inform them of a positive culture [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) in the resident's urine. Review of laboratory slips in the medical record revealed Resident #32's urine specimen was received by the laboratory 10/26/09, which was five (5) days after the physician ordered the test. The director of nursing was informed of the five (5) day delay in obtaining the urine specimen for this resident on 12/02/09 at 12:15 p.m., with no additional information provided.",2014-07-01
11209,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,367,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to assure one (1) resident of random opportunity received a therapeutic diet as ordered by the physician. Resident identifier: #75. Facility census: 116. Findings include: a) Resident #75 On 11/30/09 at approximately 6:00 p.m., a nurse aide (Employee #138) was observed feeding Resident #75. At that time, an inquiry was made as to the thickness of the resident's apple juice. Employee #138 indicated the dietary department had put two (2) packets of thickener on the resident's tray and that is what was put into the apple juice. The employee indicated she did not plan on serving the resident the apple juice, because it looked too thick. The employee also mentioned the cup of milk the resident had was not as thick as the apple juice, because it had not been mixed with as much thickener as the apple juice. After reviewing the resident's physician orders [REDACTED].#92), it became apparent that the resident's apple juice had been thickened as required and the milk had not. The physician orders [REDACTED]. Employee #92 agreed that Employee #138 should have noticed the difference in the consistency of the liquids and inquired as to why they were not the same. She also indicated nurse aides have easy access to cardex files which give instructions on how to assist residents with meals. .",2014-07-01
11210,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,323,D,1,1,TDS111,"Based on confidential family interview, confidential resident group interview, confidential resident interview, observation, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Nurses left medications on bedside tables and failed to ensure the residents ingested them; this practice places residents who wander in the facility at risk for ingesting medications left unattended on bedside tables in resident rooms. The facility also failed to promote safety for one (1) of twenty-one (21) sampled residents, by failing to apply safety mats to both sides of the resident's bed in accordance with the resident's care plan. Resident identifier: #32. Facility census: 116. Findings include: a) During a confidential interview on 12/02/09 at 10:30 a.m., a family member expressed a concern about nurses leaving medications on a resident's bedside table and asking family members to encourage the resident to take the medications. In the confidential resident group meeting held beginning at 3:30 p.m. on 12/02/09, two (2) residents in attendance reported nurses did leave medications unattended on their bedside tables. A confidential resident interview, on 12/02/09 at 12:45 p.m., confirmed medications had been left by the nurse on his/her bedside table. During an interview with the director of nursing (DON) on 12/02/09 at 3:45 p.m., she was informed of the practice of nurses leaving medications unattended in residents' rooms. b) Resident #32 Review of Resident #32's care plan revealed a focus for the resident being at risk for falls with a goal to have no falls with injury over the next ninety (90) days. An intervention listed on the care plan was to have a low bed with a ""landing strip on each side of the bed"". Observation of the resident's room, on the morning of 12/03/09, revealed she had only one (1) landing strip located on the right side of her bed. This finding was reported to the DON at approximately 11:00 a.m. 12/03/09. .",2014-07-01
11211,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,152,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify the nature of incapacity for one (1) of twenty-one (21) sampled residents determined by the physician to lack the ability to understand and make informed health care decisions. Resident identifier: #3. Facility census: 116. Findings include: a) Resident #3 Review of Resident #3's determination of incapacity statement, dated 10/28/09, revealed the physician identified the resident lacked decision-making capacity due to the [DIAGNOSES REDACTED]. During interview with the director of nursing (DON) the morning of 12/02/09, she stated the facility's practice is for the physician to note not only the [DIAGNOSES REDACTED]. When informed of Resident #3's incapacity statement, which noted only the diagnosis, she said she would bring this to the physician's attention for correction. According to W.V.C. 16-30-7. Determination of incapacity.: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..."" .",2014-07-01
11212,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,364,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure food was served to all residents in a palatable manner. This was evident for one (1) of twenty-one (21) sampled residents, whose nurse aide fed her a mixture of chocolate Health Shake and pureed baked steak during the evening meal of 11/30/09. Resident identifier: #101. Facility census: 116. Findings include: a) Resident #101 Observation of the evening meal, on 11/30/09 shortly before 6:00 p.m., revealed a nurse aide feeding Resident #101 in bed. The nurse aide poured dark brown liquid from a carton of chocolate Health Shake into a cup. The nurse aide then added the resident's golden-colored pureed baked steak into the chocolate, stirred it around with a spoon, then offered it to the resident with a straw. The resident was observed scrunching up her face when the concoction was in her mouth. The nurse aide was also observed spoon feeding the concoction to her, to which the resident responded with the same facial expression. When asked if her dinner was good, the resident did not answer. The nurse aide said the only way to get her to eat was to put something sweet on her food. review of the resident's medical record revealed [REDACTED]. Review of the physician's orders [REDACTED]. Dietary progress notes for January 2009 documented a significant weight loss for the preceding one hundred-eighty (180) days, although her body mass index (BMI) of 20 remained within normal limits, and a recommendation was made to change the Shakes to Magic Cup three (3) times daily due to the latter having more calories and protein density. During interview with the dietician on 12/01/09 at 10:00 a.m., she said she comes to the facility at least two (2) times per week. She spoke awareness of the resident's liking sweet foods and said she would look into how food is being presented to the resident. The nurse beside her (Employee #55) said the family objected to the change to Magic Cup in place of the Health Shakes but could not recall the reason why. Observation of Resident #101's lunch meal, on 12/01/09 at 12:45 p.m., revealed she was up in a geri chair in the dining room being fed by a nurse aide. She had the appropriate diet as ordered by the physician. A carton of 2% milk was at her place setting, and a cup of red-colored juice drink had been spilled onto the floor. She was observed eating mashed potatoes with no facial distortions and no choking. During an interview with the director of nursing shortly (DON) after noon on 12/02/09, the surveyor shared with her the above-mentioned observations of the 11/30/09 meal and the interview with the dietician on 12/01/09. Observation of the lunch meal, on 12/02/09, revealed Resident #101 was up in a geri chair in the dining room being fed by a nurse aide. The resident's facial expression was relaxed, and she was observed smiling at the aide feeding her and reaching out toward her at times. Her diet was appropriate as ordered by the physician. She again had a carton of 2% milk to drink. The nurse aide said they were giving her the Health Shakes three (3) times daily as a snack between meals. .",2014-07-01
11213,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,431,E,0,1,TDS111,"Based on observation and staff interview, the facility failed to label and date all vials of injectable insulin when initially opened, and failed to discard vials of injectable insulin thirty (30) days after the vials were opened. This was evident for one (1) of four (4) medication carts observed in the facility and had the potential to affect diabetics who receive insulin on the 800 hallway. Facility census: 116. Findings include: a) Observation of the medication cart on the 800 wing, on 12/02/09 at 4:30 p.m., revealed the presence of two (2) vials of insulin dated as having been opened on 11/30/09 - Humalog insulin prescribed for Resident #14 and Novolog insulin prescribed for a resident who no longer resided in the facility. Additionally, there were four (4) vials of insulin which had no dates indicating when they were opened - Novolog R prescribed for Resident #21; Novolin-R prescribed for Resident #118; Lantus prescribed for Resident #14; and Lantus prescribed for Resident #21. A nurse (Employee #80) was present during observation of the medication cart and spoke awareness that the two (2) vials of insulin opened on 10/30/09 should have been discarded thirty (30) days after opening; Employee #80 also acknowledged that the other four (4) bottles should have been labeled with the dates on which they were initially opened. During interview with the director of nursing (DON) on 12/03/09 at approximately 11:00 a.m., she was made aware of the above findings. No new information was provided at this time. .",2014-07-01
11214,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,280,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan of one (1) of twenty-one (21) sampled residents to reflect changes in interventions to address a resident's mood / behaviors. Resident identifier: #101. Facility census: 116. Findings include: a) Resident #101 Review of Resident #101's current care plan revealed a focus area for mood / behaviors as evidenced by an anxious affect, resisting care, and refusing medication. Interventions included: ""Medicate resident as ordered by physician and monitor for side effects. [MEDICATION NAME]."" and ""If resident refuses her medication, try again later."" review of the resident's medical record revealed [REDACTED]."" medication was only being given one (1) to three (3) times per month. Review of the monthly recapitulation of physician orders [REDACTED]. Medicating the resident with [MEDICATION NAME] was no longer available as an intervention to address the resident's mood / behaviors, and there was no evidence the facility revised the resident's care plan to reflect this. These findings were reported to the director of nursing shortly after noon on 12/02/09. .",2014-07-01
11215,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2009-06-18,225,E,1,0,1MWP11,"Part I -- Based on review of facility documents and staff interview, the facility failed to immediately report and thoroughly investigate two (2) allegations of abuse / neglect in accordance with State law. This deficient practice affected two (2) former residents. Resident identifiers: #10 and #11. Facility census: 8. Findings include: a) Resident #10 Review of facility documents found that, on 01/31/09, Resident #10 reported to facility staff he had an incontinence episode because staff did not answer his call light in a timely manner. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. The facility documents concerning the allegation did not contain evidence that a thorough investigation was conducted. No statements were obtained from staff members present during the alleged incident, nor was there evidence to reflect the facility attempted to determine if corrective action was needed to prevent future incidents. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of neglect was reported and thoroughly investigated in accordance with State law. b) Resident #11 Review of facility documents found that, on 01/07/09, Resident #11 reported to a facility staff member that a nurse had been rough with her. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of abuse was reported in accordance with State law. --- Part II -- Based on random observation, staff interview, review of the list of skilled unit employees provided by the facility, review of staffing assignment sheets, and review of sampled employee personnel files, the facility failed to conduct thorough investigations of the past histories of individuals working on the skilled nursing unit and providing care to the unit's residents. This deficient practice had the potential to affect more than an isolated number of residents currently residing in this facility. Facility census: 8. Findings include: a) On 06/16/09, a request was made for a list of all current employees of this skilled nursing facility. Review of the list provided found sixteen (16) names - fifteen (15) nursing staff members and one (1) activity staff member. Random observations of the facility, on 06/16/09 at approximately 11:00 a.m., found two (2) individuals providing therapy services to residents on the skilled nursing unit. Upon introductions, it was determined these individuals were a physical therapy aide and a physical therapy assistant. Interviews with these individuals revealed the physical therapy aide, along with another physical therapy aide not currently present, worked full time on the skilled unit. None of these individuals had been included in the list of employees provided by the facility. An interview with the registered nurse clinical coordinator (Employee #2) was conducted at 11:30 a.m. on 06/16/09. It was brought to her attention that three (3) individuals providing care to residents on the unit had not been included in the list of employees provided. During this same interview, she was asked how regularly scheduled nursing staff who failed to report to work were replaced. Employee #2 stated they first try to cover the shift with another of the regular nursing staff, and if not successful, then pull from the nursing staff who regularly work for the hospital. She was asked to provide records of all individuals providing nursing-related services for facility residents during the previous thirty (30) days. Employee #2 produced staffing assignment sheets from 05/01/09 through 06/17/09. Of the forty-eight (48) staffing days reviewed, on twenty-two (22) days (or an average of 45.8% of the time), the facility utilized the services of nine (9) nursing personnel who were not listed as employees. A meeting with two (2) human resource staff members was held at 1:00 p.m. on 06/18/09. The list of these nine (9) individuals, who provided direct care to facility residents but who were not included on the employee list, was provided to them. The personnel files of these individuals were reviewed. Of the nine (9) nursing staff members pulled from the hospital side of the facility, seven (7) of them did not have evidence of statewide criminal background investigations having been conducted. It was determined the facility utilized an entity to conduct criminal background investigations that only screened counties in which the employee had listed as a residence on their employment application. The human resource personnel were asked how they had determined these seven (7) nursing staff members did not have criminal convictions in counties not listed on their employment applications, which would make them unsuitable for employment on the skilled unit. They were unable to provide evidence of background checks having been conducted in other counties in the State, in which crimes may have been committed by these seven (7) nursing staff members. b) Review of the personnel files of four (4) recently hired employees found the facility failed to conduct criminal back ground investigations for two (2) nursing staff members who listed other states as residences. c) This thorough review of the facility's practices in screening for criminal convictions determined the facility did not make reasonable and prudent inquiries into the backgrounds for all the individuals working and providing care for the residents living in the skilled nursing unit. .",2014-07-01
11216,"REYNOLDS MEMORIAL HOSPITAL, D/P",515112,800 WHEELING AVENUE,GLEN DALE,WV,26038,2009-03-27,329,G,1,0,1UMJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of eight (8) sampled residents, to ensure medications were not given without adequate indications of use and at an excessive dosage. The facility also failed to ensure that alternative causes for behaviors were ruled out and non-pharmacologic interventions were attempted without success prior to the use of psychoactive medications. Resident #19 experienced harm as evidenced by oversedation and decreased respirations after administration psychoactive medications. Resident identifier: #19. Facility census: 18. Findings include: a) Resident #19 Medical record review, on 03/25/09, revealed Resident #19 was admitted to the facility on [DATE]. On 09/15/08, a physician order [REDACTED]. Review of the nursing progress notes failed to record any behaviors to indicate the need for [MEDICATION NAME]. On 09/16/08 at 13:49 (2:49 p.m.), nursing progress note indicated, "". . . had been resting in chair very drowsy arouse when name called tho very weak, color dusky O2 sat on 3 liters 96 %, apical rate 92 and regular, faint bowel sounds, abdomen firm and distended had small loose stool this am (morning)."" On 09/18/08, the physician ordered [MEDICATION NAME] 0.5 mg by mouth now for agitation and then [MEDICATION NAME] 0.5 mg every six (6) hours as needed for constant position changes, along with [MEDICATION NAME] 12.5 mg by mouth at night for the [DIAGNOSES REDACTED]. A nursing progress note, dated 09/18/08 at 18:23 (6:23 p.m.), revealed, ""Pt becoming more restless and confused, attempts to get out of bed unassisted, family members cannot reason with him, medicated for pain."" A subsequent nursing progress note, dated 09/19/08 at 00:19 (12:19 a.m.), stated, ""1915 Pt voice was heard loudly from room out at nurses station, wife was holding pt's hands. Pt was agitated was to leave, she was trying to calm and reported by daughter bent her fingers back, he was out one side of the bed then the other, up in a chair."" A nursing progress note, dated 09/20/08 at 06:06 (6:06 a.m.), stated, ""Pt rested at long intervals tho when awake is confused, bed alarm sounded several times when pt turned in bed, wanting to go home pt reassured that he will need to stay here for breakfast, to seemed satisfied with answers."" Nursing progress note, dated 09/20/08 at 23:31 (11:31 p.m.), stated, ""@22:45 notified Dr. (name) patient is disrobing, pulling at TLC, IV, and O2 tubing getting out of bed unassisted. Insisting on going home, wife is present and can not calm patient . Order received for [MEDICATION NAME] 0.5 mg IM X 1 dose now."" A physician's orders [REDACTED]."" A nursing progress note, dated 09/20/08 at 23:57 (11:57 p.m.), stated, ""Pt very drowsy and lethargic, skin warm and dry, responded weakly when pt into bed from recliner chair by son and 2 staff members, O2 per nasal canula at 3 liters, sat 97 -100 %, after pt in bed, very sedated, Cheyne Stokes respirations."" A nursing progress note, dated 09/20/08 at 23:57 (11:57 p.m.), stated, ""periods of apnea [MEDICATION NAME] for 1 minute and more, when breathing 24 resp over 30 seconds wit exp wheezing, dr chin beeped X 1, apical rate 60 and irregular blood sugar 117."" An entry, dated 09/21/08 at 00:05 (12:05 a.m.), stated, ""Sa tx given by Rt resp regular, pt responds by opening eyes."" Following this excessive sedation, the physician ordered, on 09/21/08, ""(arrow up) [MEDICATION NAME] 25 mg at hs (hour of sleep) at pm (night)."" A nursing progress note, dated 09/23/08 at 14:33 (2:33 p.m.), stated, ""[MEDICATION NAME] for [MEDICAL CONDITION] AEB abusive behaviors. No adverse reactions noted at this time."" On 09/28/08, Resident #19 was transported to the emergency room after the nurse was unable to find pedal pulses; he was subsequently admitted to the hospital for a blood clot. The facility failed to adequately identify behaviors, complete a thorough assessment to determine possible causes of the behaviors, and provide non-pharmacological interventions to help eliminate behaviors prior to administering psychoactive medications. The facility used pharmacologic interventions which sedated and depressed his respirations. On the evening of 03/25/09, the head nurse (Employee #7) revealed this resident was at the facility prior to her employment. Following review of the medical record, she did not produce any additional information to dispute these findings. .",2014-07-01
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
11218,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-03-16,154,D,1,0,81RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not inform the legal representatives of three (3) of five (5) sampled residents when changes were made to their care and/or treatment. Resident identifiers: #73, #85, and #8. Facility census: 116. Findings include: a) Residents #73, #85, and #8 A review of MEDICATION ORDERS FOR [REDACTED]. 1. Resident #73 Record review revealed a physician's orders [REDACTED]."" On 12/08/10, another physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; these areas were blank on the above telephone orders. - 2. Resident #85 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. - 3. Resident #8 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. -- b) An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the nurses were all educated to notify families of residents when a change was made in medications. .",2014-07-01
11219,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-03-16,309,D,1,0,81RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interviews, the facility did not ensure one (1) of five (5) sampled residents received care and services to attain or maintain the highest practicable physical well being. Resident #112 received two (2) doses of a short-acting benzodiazepine ([MEDICATION NAME] 0.25 mg), contrary to the physician's orders [REDACTED]. At 4:00 p.m. on the same day, she received a dose of a short-to-intermediate acting benzodiazepine ([MEDICATION NAME] 0.5 mg). Both [MEDICATION NAME] and [MEDICATION NAME] have sedative / hypnotic side effects, and the resident's sons reported she experienced a decrease in her level of consciousness, which was not addressed until they brought it to the staff's attention. Facility census: 116. Findings include: a) Resident #112 In an interview on 03/15/11 at 11:30 a.m., Resident #112's two (2) sons reported the resident received two (2) doses of [MEDICATION NAME] and a dose of [MEDICATION NAME] on the same day (on 02/26/11). The next day (on 02/27/11), their mother's level of consciousness changed. According to her sons, she was sedated, could not eat or drink, and was very stiff and not moving in her bed. She could not open her mouth, and they were having difficulty getting her awake. They asked the nurse if the [MEDICATION NAME] was maybe too strong for their mother, and they wanted the physician notified. When the physician was called, he discontinued the [MEDICATION NAME]. - Record review revealed an order, dated 12/29/10, for: ""[MEDICATION NAME] 0.25 mg QD (daily) and [MEDICATION NAME] 0.25 mg PRN (as needed) for increased anxiety."" On 02/15/11, the physician discontinued the [MEDICATION NAME] 0.25 mg QD. (The remaining order for [MEDICATION NAME] allowed staff to administered one (1) 0.25 mg tab by mouth every day as needed for anxiety.) On 02/26/11 at 2:30 p.m., the physician discontinued the [MEDICATION NAME] 0.25 mg PRN and ordered [MEDICATION NAME] 0.5 mg every six (6) hours as needed. On 02/27/11 at 6:00 p.m., the physician discontinued the [MEDICATION NAME] and ordered lab studies. - A review of nursing notes for February 2011 revealed the resident was cursing, hitting staff, hitting other residents, yelling, climbing out of bed, and throwing food. The licensed staff administered the [MEDICATION NAME] as needed. Nursing notes did not indicate the resident's level of consciousness declined after doses of the [MEDICATION NAME] 0.25 mg were administered. Further review of the nursing notes revealed the following entries: - On 02/26/11 at 7:00 a.m. (quoted verbatim), ""Resident (illegible) nasty & yelling @ 3:20 A (a.m.) climbing out of bed, given snacks per her request - yelling, climbing, throwing crackers. Cursing staff. Very angry & upset. Given prn [MEDICATION NAME] /c (with) relief. Monitor."" (According to documentation on the February 2011 Medication Administration Record [REDACTED].) - On 02/26/11 at 11:30 a.m. (quoted verbatim), ""Restless this a.m. (morning) /c (arrow pointing up) anxiety. PRN given /c relief. OOB (out of bed) in scoop chair, sons in at lunch."" (According to documentation on the February 2011 MAR, a dose of [MEDICATION NAME] was given at 9:00 a.m. on 02/26/11.) - On 02/26/11 at 2:30 p.m. (quoted verbatim), ""Pt (patient) very aggitated. cussing staff. trying to get out of chair constantly yelling at passerbyers in hall. Sons aware unable to come in, MD aware. N.O. (new order) obt(ained), med adm(inistered). POA's aware."" (This note did not contain the name of the new drug that was ordered, but the only new order received on 02/26/11 discontinued the [MEDICATION NAME] 0.25 mg PRN and started the [MEDICATION NAME] 0.5 mg every six (6) hours as needed.) A subsequent nursing note, at 5:00 p.m. on 02/26/11, stated (quoted verbatim), ""Res(ident) agitated. Cussing staff, trying to get out of chair and hitting @ staff. Tried 1 on 1 /c no results. Gave res. snack. She threw it on the floor. Took res to her room. Res would not calm down. Gave PRN [MEDICATION NAME] /c good results. Res sitting quietly in scoop chair. Will cont(inue) to monitor."" - According to the MAR, the resident received [MEDICATION NAME] 25 mg at 3:00 a.m. and 9:00 a.m. on 02/26/11. The [MEDICATION NAME] was discontinued at 2:30 p.m. on 02/26/11, and at 4:00 p.m., [MEDICATION NAME] 0.5 mg was administered. - Further review of the nursing notes revealed the following entries: - On 02/27/11 at 3:30 a.m., ""Went back to bed at 12:30 a.m. - Sleeping presently. No behaviors."" - On 02/27/11 at 1:30 p.m. (quoted verbatim), ""OOB in scoop chair drowsey but arouses easily. Sch(eduled) meds given. Pleasant cooperative /c nursing care. Anxiety level low. Family in to visit - concern [MEDICATION NAME] may be too much d/t (due to) being too drowsey."" No further nursing documentation concerning the resident's status was recorded until 02/27/11 at 6:00 p.m., at which time the nurse wrote (quoted verbatim), ""Resident up in chair and sleepy. Took meds /c some difficulty D/T shaking head back & forth & swinging arms. Sons here now & concerned because resident is sleepy & hard to awaken. ... Resident doesn't appear to be in any distress. Sons continue to be upset. They feel she should be more alert. Assured them resident had not had any seditives administered in the last 24 hrs. Offered to call MD & send pt to ER (emergency room ). Supervisor (name of registered nurse - RN) here & also talked /c them. (Name of physician) notified. N.O. D/C (discontinue) [MEDICATION NAME] - Do U/A (urinalysis) & labs in AM (morning). (Name of RN) & this nurse went back to residents room to check pt & talk /c sons. They were feeding resident - who appeared fully awake & was eating small amounts @ a time. No S/S (signs / symptoms) distress. Sons aware of new orders. Will continue to observe."" - Further record review revealed a social service note, dated 02/28/11, stating (quoted verbatim), ""I met /c ADON (assistant director of nursing) and Director of Nursing with a mtg (meeting) /c family concerns regarding medication given to (Resident #112's first name). Director of Nursing explained that here was an error and apologized to the family and noted that the issue would be looked into. Family stated they were still upset about the situation regardless. SS (social services) will continue to monitor and offer support as needed."" - An interview with the administrator, on 03/16/11 at 9:00 a.m., confirmed the resident was given two (2) doses of [MEDICATION NAME] on the morning of 02/26/11, and the order to discontinue the [MEDICATION NAME] was received from the physician at 2:30 p.m. on 02/26/11, along with a new order for [MEDICATION NAME] 0.5 mg every six (6) hours as needed. Per the administrator, the resident received [MEDICATION NAME] to calm her down.",2014-07-01
11220,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-03-16,253,C,1,0,81RJ11,". Based on observations and staff interview, the facility did not provide effective housekeeping services to maintain a clean environment for all residents. Facility census: 116. Findings include: a) An observation of the facility's hallways in the front of the building and on each unit, on 03/15/11 beginning at 3:00 p.m., revealed built-up debris along the cove base and in the corners of the floor on the hallways. An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the housekeeping staff had cleaned along the baseboards and in the corners of each hallway about three (3) months ago. She stated, ""These areas are very hard to keep clean."" .",2014-07-01
11221,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-09-16,280,D,1,0,7I0T11,"Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan for one (1) resident reviewed to accurately describe the care and services to be furnished to that resident. Resident identifier: #73. Facility census: 86. Findings include: a) Resident #73 Observation, during a random tour of the facility on 09/16/09 at 11:00 a.m., found this resident's bed to consist of a mattress in the floor. The mattress was dressed in linens, and the resident was currently not in the bed. Later in the afternoon of 09/16/09, the resident was observed to be lying on the mattress. The resident's plan of care, when reviewed, noted the resident had experienced numerous falls and facility staff had determined the best option to prevent further falls with injuries was to place the resident's mattress in the floor. The resident's care plan made no mention of the special needs related to this intervention. The care plan did not describe how the resident should be moved out of the bed, how and if the resident should receive food / snacks in bed, etc. Further review of the record also disclosed no evidence that the resident's responsible party had been included in the development of this plan to have the resident's bed in the floor. Facility staff - including the director of nurses and the social worker assigned to this resident, when interviewed, could provide no evidence that the resident's care plan was revised to reflect the special needs related to the care of this resident. Staff also confirmed the resident's responsible party was not involved with the decision to place this resident's bed in the floor.",2014-07-01
11222,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2011-01-11,225,D,1,0,LEB011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility records, policy review, resident interview, and staff interview, the facility failed to immediately report allegations of neglect, and the results of the facility ' s internal investigations into these allegations, to the proper State agencies in accordance with State law for two (2) of sixteen (16) sampled residents. Resident identifiers: #52 and #36. Facility census: 85. Findings include: a) Resident #52 A review of Resident #52's medical record revealed this alert and oriented female had a history of [REDACTED]. Review of the facility's concern forms revealed that, on 12/06/10, Resident #52 reported to an activities employee (Employee #17) that she had a nosebleed and turned on her call light to summon help. When the nurse aide arrived, the resident told her to get the nurse. The resident stated that, when the nurse (Employee #29) arrived, she stated that she didn't have much experience with nosebleeds and gave her some ice in a plastic bag, which the nurse instructed the resident to put it on her ""wrist""; the nurse then left the room. Resident #52 further stated that it was a long time before another nurse (Employee #123) came in to check on her. Employee #17 filed a written report of this incident on a ""Suggestion or Concern"" form and submitted it to the facility. During an interview with Resident #52 at 2:00 p.m. on 01/11/11, she stated she did have nosebleeds every once in awhile and that the nurses or aides always stayed with her until it stopped except for one (1) time when ""a new nurse didn't know what to do"" and left her alone. She stated that she told someone about it, because she was upset that no one stayed with her. There is no evidence in the clinical record that this allegation of neglect was reported to the State survey and certification agency, adult protective services (APS), or the regional ombudsman. During an interview with the social worker (Employee #132) and the director of nurses (DON - Employee #37) at 4:30 p.m. on 01/10/11, they were asked whether the facility had reported to State agencies the allegation made by Resident #52 that the nurse did not know what to do to treat her nosebleed and had left her alone after providing her with an uncovered ice bag. Both confirmed this was not reported, but Employee #132 did present documentation of the facility's internal investigation to this surveyor at 1:00 p.m. on 01/11/11. Review of the facility's internal investigation by a clinical coordinator (Employee #105) verified that Employee #29 had given the resident ice (without a cloth cover) and left her alone to get another nurse. Employee #105 documented that she had provided educational counseling to Employee #29, addressing both the facility policy regarding nosebleeds and the use of a cloth cover on ice bags. Review of the facility's policy regarding nosebleeds found it did not include the use of ice to treat a nosebleed, but it did state: ""Apply firm and equal pressure to both sides of the bridge of nose for 10 to 15 minutes to stop bleeding."" and ""Monitor resident until bleeding has stopped."" -- b) Resident #36 A review of Resident #36's medical record revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her physician determined she lacked the capacity to understand and make informed health care decisions, and her son, whom she designated as her medical power of attorney representative (MPOA) was acting on her behalf. The resident exhibited challenging behaviors including refusal of medications and/or foods and physically aggression. On 11/15/10, the resident's MPOA made a complaint to a nurse (Employee #37) alleging: - When he visited at approximately 11:00 a.m. on 11/13/10, his mother's breakfast was sitting in the room and had not been touched. He stated that this had happened again on 11/15/10 when he visited at 10:30 a.m.; - He found her evening snack sitting on her stand unopened; - He stated that he could not find her call bell on 11/13/10, and when his sister visited on 11/07/10 and pushed the call bell, they waited twenty-five (25) minutes for a response before going to the nurses' desk for assistance; and - Her wheelchair was dirty with dried food along the side. In an interview with the MPOA at 6:45 p.m. on 01/19/11, he stated he was very concerned about the resident not getting the assistance she needed to eat, because she was losing weight. He stated she required total feeding by staff because of her [MEDICAL CONDITION] and that she would only eat a little at a time. He stated that, after he made his complaint, they cleaned the wheelchair, but when he visited on 01/18/11, it was again dirty. These allegations of neglect were not reported to the appropriate State agencies as required, although a record of the complaint was made on a ""Suggestion or Concern"" form in the facility. While there was evidence that an internal investigation was completed and that the nurse aide had not attempted to feed the resident (which resulted in education and counseling for the aides), there was no evidence this information was reported to the Nurse Aide Registry. During an interview with the DON at 11:15 a.m. on 01/11/11, she acknowledged that the above allegations had not been reported but stated she had told the MPOA they were ""taken care of"". .",2014-07-01
11223,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2011-01-11,325,G,1,0,LEB011,". Based on record review, staff interview, and family interview, the facility failed to prevent weight loss in one (1) of sixteen (16) sampled residents by not providing the nutritional care and services deemed necessary and planned for in the nursing interventions of the comprehensive plan of care to meet the needs of the resident's clinical condition. Resident identifier: #6. Facility census: 85. Findings include: a) Resident # 6 A review of Resident #6's medical record revealed she had resided at the facility since 02/22/07. She was alert, confused, and pleasant and her resident assessment from October 2010 indicated she exhibited no challenging behaviors (such as refusing care). She received a mechanically altered diet and required substantial assistance for meals and snacks. Her weights began falling in November 2010 as follows: On 10/10/10 - 110# On 11/10/10 - 105# On 12/10/10 - 102# On 01/11/11 - 87# This represented a significant unplanned weight loss of 14.7% in thirty (30) days; a weight loss of 20.91% in ninety (90) days; and a weight loss of 21.6% in one hundred-eighty (180) days. Further review of the medical record disclosed documentation by the aides of the resident's oral intake, but there was no mention in the nurses' notes of any concerns about her weight loss, no assessment was completed to explore causal factors of her poor oral intakes as reported by the aides, nor was there any description of her eating habits or needs. During an interview with the dietary manager at 2:10 p.m. on 01/11/11, she stated she obtained the information needed for her resident assessments from the nurse aide sheets and direct observation, because there was usually nothing in the nurses' notes. The dietary manager reported she was responsible for completing the care plan and nutrition section of the resident assessment instruments. During an interview with the DON at 11:15 a.m. on 01/11/11, she stated she had recognized the lack of documentation regarding the eating abilities and habits of the residents, especially the ones who were experiencing weight loss. She presented to this surveyor an educational posting issued to the nurses on 11/23/10, instructing them to document the specifics when a resident refuses nourishments and that staff should attempt again later. However, review of Resident #6's medical record from 11/23/10 to 01/11/11 found nothing in the nursing notes addressing concerns about the resident's poor meal intake or any refusal of meals. .",2014-07-01
11224,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2011-01-11,514,D,1,0,LEB011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure nursing staff was documenting the nutritional status of facility Residents as directed during a facility in-service. This was true for three (3) of sixteen (16) sampled residents. Resident identifiers: #36, #67, and #6. Facility census: 85. Findings include: a) Resident #36 A review of Resident #36's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her physician determined she lacked the capacity to understand and make informed health care decisions, and her son, whom she designated as her medical power of attorney representative (MPOA) was acting on her behalf. The resident exhibited challenging behaviors including refusal of medications and/or foods and physically aggression. An assessment by the speech language pathologist, on 01/29/10, suggested the facility provide to Resident #36 finger foods, increased variety, and small amounts of foods at a time. The resident required the supervision of one (1) staff member for meals at that time but could feed herself. No further assessment or evaluation of her ability to feed herself had been performed by occupational, physical, or speech therapy after 01/29/10. On 08/10/10, Resident #36 weighed 135 pounds (#). She experienced an unplanned weight loss, and 09/10/10, she weighed 121#; from that point, she continued to have progressive weight loss each subsequent month. On 11/10/10, she weighed 108#, and the nurse aides' documentation reflected her meal intake was poor. During an interview with the resident's son / MPOA at 6:45 p.m. on 01/19/11, he stated he was very concerned about the resident not receiving the assistance she required to eat, because she was losing weight. He reported she was feeding herself until September or October 2010, but she could no longer raise her arms to feed herself and required total feeding due to her [MEDICAL CONDITION]; he also stated she would only eat a little at a time and would then become irritated and refused to continue eating. He and/or other family members visited several times a week and, on numerous days, they have found snacks sitting in her room unopened and trays sitting untouched in front of her. On 11/15/10, he reported his concerns to the nurses and told them he wanted to make sure staff fed the resident both meals and snacks. A review of the actions taken by the facility after these complaints were received revealed the director of nurses (DON) confirmed the nurse aides were not always feeding the resident; instead they were setting up her meal tray and expecting her to eat on her own, as her comprehensive assessment (with an assessment reference date of 08/18/10) and her care plan stated she only needed ""limited assistance"". On 11/24/10, her care plan was changed to ""attend meals in total assist DR (dining room)"", which meant, according to the DON, she was now being fed by staff. A review of the nurses' notes dated 08/24/10, revealed, "".....seems to need extra encouragement at meals with intake."" This was the only entry by nursing to address her nutritional status or ability to feed herself, until after the complaints were made by the MPOA on 11/15/10. During an interview with the DON at 11:15 a.m. on 01/11/11, she stated she had recognized the lack of documentation regarding the eating abilities and habits of the residents, especially the ones who were experiencing weight loss. She presented to this surveyor an educational posting issued to the nurses on 11/23/10, instructing them to document the specifics when a resident refuses nourishments and that staff should attempt again later. However, review of Resident #36's medical record from 11/23/10 until 01/11/11 found thirty-nine (39) refusals of nourishment documented by the nurse aides and only one (1) entry in the nurses' notes discussing her nutritional intake. On 11/23/11, the dietary manager documented that Resident #36 weighed 108# and had a significant weight loss of 27 pounds in 1 year, with a 7.69% weight loss in thirty (30) days; a 20.0% weight loss in ninety (90) days; and a 20.0% weight loss in one hundred-eighty (180) days. During an interview with the dietary manager at 2:10 p.m. on 01/11/11, she stated she obtained the information needed for her resident assessments from the nurse aide sheets and direct observation, because there was usually nothing in the nurses' notes. Although the resident's record revealed that she weighed 122# on 12/10/10 (which would have indicated a 14# gain), the accuracy of this weight was questionable. Her weight was 99# on 01/11/11, which represented another significant weight loss of 18.85% in thirty (30) days; a 15.38% weight loss in ninety (90) days; and a 26.67% weight loss in one hundred-eighty (180) days. -- b) Resident #67 A review of Resident #67's medical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. This resident's weights were recorded as follows: On 10/10/10 - 95# On 11/10/10 - 91# On 12/10/10 - 92# On 01/11/11 - 86# This represented an unplanned weight loss of 6.52% in thirty (30) days; a 9.47% weight loss in ninety (90) days; and 9.47% weight loss in one hundred-eighty (180) days. Her last assessment by the registered dietitian (RD) was recorded on 08/11/10, at which time she was noted to have had a significant weight loss of 16.8# in one (1) month and 30# weight loss in six (6) months. According to her care plan dated 11/17/10, she was a total assist for meals and was to receive a dietary supplement. Although the resident had not regained weight after the loss in August 2010, her weight remained stable until an additional weight loss was identified in January 2011. During an interview with the dietary manager at 2:10 p.m. on 01/11/11, she stated the family had become concerned about the resident's poor intake in December 2010 and asked if she could receive frequent small feedings. The dietary manager stated she had informed the RD of this on 01/07/11, when the RD was at the facility, but it had not yet been addressed. She stated she obtained the information needed for her resident assessments from the nurse aide sheets and direct observation, because there was usually nothing in the nurses' notes. During an interview with the DON at 11:15 a.m. on 01/11/11, she stated she had recognized the lack of documentation regarding the eating abilities and habits of the residents, especially the ones who were experiencing weight loss. She presented to this surveyor an educational posting issued to the nurses on 11/23/10, instructing them to document the specifics when a resident refuses nourishments and that staff should attempt again later. However, review of Resident #67's medical record from 09/15/10 to 11/23/10 (when the education posting was circulated) and to 01/11/11 found not entries addressing concerns about the resident's poor meal intake or any refusal of meals. -- c) Resident # 6 A review of Resident #6's medical record revealed she had resided at the facility since 02/22/07. She was alert, confused, and pleasant and her resident assessment from October 2010 indicated she exhibited no challenging behaviors (such as refusing care). She received a mechanically altered diet and required substantial assistance for meals and snacks. Her weights began falling in November 2010 as follows: On 10/10/10 - 110# On 11/10/10 - 105# On 12/10/10 - 102# On 01/11/11 - 87# This represented a significant unplanned weight loss of 14.7% in thirty (30) days; a weight loss of 20.91% in ninety (90) days; and a weight loss of 21.6% in one hundred-eighty (180) days. Further review of the medical record disclosed documentation by the aides of the resident's oral intake, but there was no mention in the nurses' notes of any concerns about her weight loss, no assessment was completed to explore causal factors of her poor oral intakes as reported by the aides, nor was there any description of her eating habits or needs. During an interview with the dietary manager at 2:10 p.m. on 01/11/11, she stated she obtained the information needed for her resident assessments from the nurse aide sheets and direct observation, because there was usually nothing in the nurses' notes. The dietary manager reported she was responsible for completing the care plan and nutrition section of the resident assessment instruments. During an interview with the DON at 11:15 a.m. on 01/11/11, she stated she had recognized the lack of documentation regarding the eating abilities and habits of the residents, especially the ones who were experiencing weight loss. She presented to this surveyor an educational posting issued to the nurses on 11/23/10, instructing them to document the specifics when a resident refuses nourishments and that staff should attempt again later. However, review of Resident #6's medical record from 11/23/10 to 01/11/11 found nothing in the nursing notes addressing concerns about the resident's poor meal intake or any refusal of meals.",2014-07-01
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
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
11250,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-09-15,225,D,1,0,1GSN11,"Based on record review and staff interview, the facility failed to screen an applicant for employment for evidence of past criminal prosecutions outside of WV when this individual revealed having resided in at least three other states. This was evident in one (1) of seven (7) sampled employees whose personnel files were reviewed. Employee identifier: #92. Facility census: 111. Findings include: a) Employee #92 A review of Employee #92's personnel file revealed this individual had disclosed having resided in three states outside of WV. However, there was no evidence in the personnel file to reflect the facility had made a reasonable effort to uncover any past criminal prosecutions in these other states which would indicate the applicant was unfit for service in a nursing facility. This was confirmed during an interview with the business office staff in the early afternoon of 09/15/09.",2014-07-01
11251,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2010-03-18,165,D,1,0,8Q6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to assure one (1) of four (4) sampled residents was afforded the right to voice grievances via their legal representative without reprisal. Resident identifier: #2 Facility census: 118. Findings include: a) Resident #2 During an interview with Resident #2's legal representative / family member conducted on 03/17/10 at 12:00 p.m., the legal representative stated that, when she had previously expressed concern to the facility about Resident #2's care, she was told that if she was not happy with the care the resident received, the facility would assist her in finding alternate placement. The legal representative stated she no longer brings complaints or concerns to the attention of the facility out of fear the resident would be forced to move to another facility. A review of the facility's grievance / complaint reports found Resident #2's family met with staff members on 02/03/10 at 3:10 p.m., related to concerns that the resident received a double dose of [MEDICATION NAME]. The hand-written record of the meeting contained the following: ""Family has been given option of replacement if they are not satisfy (sic) w/ (with) resident's care & there (sic) response was we don' t want him replaced it is to (sic) convienced (sic) for their mother to visit."" In ann interview was conducted with the administrator (Employee #1) on the morning of 03/18/10, he stated he attended the 02/03/10 meeting and did offer to assist the family in finding alternate placement if they were not satisfied with the care provided by the facility.",2014-07-01
11252,GRANT COUNTY NURSING HOME,515151,27 EARLY AVENUE,PETERSBURG,WV,26847,2010-07-16,157,D,1,0,F0GM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, incident report review, family interview, and staff interview, the facility failed to notify the resident ' s legal representative or an interested family member and/or the physician in a timely manner of an accident with injury and/or potential for the need of medical intervention for one (1) of eight (8) sampled residents. Resident identifier: #19. Facility census: 107. Findings include: a) Resident #19 A review of Resident #19's medical record revealed she fell at 1:30 a.m. on Saturday, 05/22/10, and sustained a hematoma over the left eye. The incident report filed by the nurse (Employee #13) indicated the physician was not informed and that the daughter (not the resident's legal representative) was informed of the fall over thirteen (13) hours later at 2:40 p.m. on 05/22/10. At 8:20 p.m. on 05/23/10, a nurse recorded the following assessment in the resident's nursing notes: ""97.8 122/58 76 21 (these are temperature, blood pressure, pulse, and respirations) Sats (blood oxygen saturation level) 80% room air; res (resident) up ambulating per normal; 0 (no) C/O (complaints of) discomfort except when palpating small hematoma upper medial L (left) eyebrow; retook Sats (sign for after) 5 min Sats now 70% then dropped to 64%; res with C/O feeling cold; fingers with bluish tinge and cold; O2 (oxygen) @ 2L (liters) via concentrator via N/C (nasal cannula) attached to res."" This entry was made by entered by a licensed practical nurse (LPN - Employee #15). An assessment of the resident, at 5:00 a.m. on 05/24/10, stated: ""... bruising remains to L eye and L side of face, bruising noted under R (right) eye also - has quarter size knot on inner side of eye brow L which is tender to touch."" At 10:45 a.m. on 05/24/10, the resident's daughter filed a complaint with the social worker (Employee #14), because of the thirteen (13) hours that had lapsed before she was contacted. During a telephone interview with the daughter at 8:00 p.m. on 07/01/10, she verified she had not been notified until 2:40 p.m. and that she knew her brother (the resident's legal representative) had not been called. The attending physician was notified at 2:15 p.m. on 05/24/10 of the recent fall and the hematoma and [MEDICAL CONDITION] to lower eyelid. An x-ray was ordered at that time and neurological monitoring was started. The resident's son was not notified until 2:20 p.m. on 05/24/10, after the complaint was filed, at which time he was also notified that an x-ray had been ordered. The x-ray was completed later the same day. This was verified by the director of nursing (DON) and by the documentation attached to the complaint. The nurse who had failed to notify the family was disciplined. During an interview with the DON at 2:10 p.m. on 07/15/10, she acknowledged the accuracy of the documentation but stated she did not know why the nurses had waited to notify the family or the physician, except that it was the weekend and she was not present in the facility. .",2014-07-01
11253,GRANT COUNTY NURSING HOME,515151,27 EARLY AVENUE,PETERSBURG,WV,26847,2010-07-16,279,E,1,0,F0GM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of work assignments, observations, and staff interview, the facility failed to develop a comprehensive care plan (to include the interventions suggested in the review of the fall plans) and failed to communicate these interventions to all caregivers for four (4) of eight (8) sampled residents resulting in the potential of increased falls for these residents. Resident identifiers: #16, #37, #59, and #19. Facility census: 107. Findings include: a) Residents #16, #37, #59, and #19 During the course of a complaint investigation which included allegations related to falls, observation found the care plans for addressing falls are kept in each resident's individual medical record and are not accessible to the nursing assistants providing direct care to the residents. This was verified at 1:15 p.m. on 07/15/10 by a licensed practical nurse (LPN) on the 300 hall (Employee #2) and shortly after by an LPN on the 200 hall (Employee #1). In an interview with the director of nursing (DON) at 2:00 p.m. on 07/15/10, she was asked to review the process for communicating the physician's orders [REDACTED]. She acknowledged the nursing assistants did not have direct access to the residents' medical records and reported it was the nurse's responsibility to transfer information from the individual resident's care plan to the kardex, which was accessible to the nursing assistants. The DON produced a facility policy outlining this. The DON and the nurse surveyor reviewed together the following discrepancies between the care plan and/or physician's orders [REDACTED].#16, #37, #59, and #19. - 1. Resident #16 A review of the clinical record revealed Resident #16 was admitted on [DATE] and had been assessed as a high fall risk resident with a history of multiple falls, the most recent on 05/27/10. According to his resident assessment instrument, the interdisciplinary team was to address falls on his care plan. His kardex called for the use of a TAB alarm (which was observed in use at 6:30 a.m. on 07/15/10) and the use of a reclining wheelchair with pommel wedge cushion, back rest with side supports, and cervical neck pillow. There was no mention of these interventions in the resident's current care plan or physician's orders [REDACTED]. During an interview with a nursing assistant (Employee #8) at 11:00 a.m. on 07/15/10, she stated the resident did use the above describe chair when up and did have a TAB alarm. - 2. Resident #37 A review of the clinical record revealed Resident #37 was admitted on [DATE] and had been assessed as a high fall risk with a history of multiple falls while at the facility, the most recent ones having occurred on 02/18/10, 02/25/10, and 06/11/10. His kardex indicated he was to have a sensor alarm and a secure care bracelet, and there was a checkmark by ""Fall Interventions"", but there was no additional information in the space provided to explain what interventions the nursing assistant was responsible for using. When the DON was asked to describe ""Fall Interventions"" at 11:20 a.m. on 07/15/10, she referred to the falls care plan located in the chart, which had a check-off list of thirteen (13) interventions under the title ""Interventions"". The DON acknowledged, however, that unless they were also written on the kardex, the nursing assistant would not know which interventions were checked. Three (3) of the checked interventions should have been on the kardex and were not. They were: ""Remind to use call light; Assure adequate lighting in the room; and Maintain clear pathways."" In addition, the resident's falls care plan did not indicate any alarm use at all, although there was a physician's orders [REDACTED]. In an interview with a nursing assistant (Employee #9) at 1:15 p.m. on 07/15/10, she was asked what was included in ""Fall Interventions"" and replied that it was usually something not on the paper that the nurse wanted done and she would write it out. This was verified in an interview with the nurse (Employee #16) at 1:20 p.m. on 07/15/10. - 3. Resident #59 A review of the clinical record revealed Resident #59 was admitted on [DATE] and had been assessed as a high fall risk, with falls recorded on 06/05/10 and 07/06/10. He had an order for [REDACTED]. - 4. Resident #19 A review of the medical record revealed Resident #19 was admitted on [DATE], was assessed as high fall risk, and had three (3) recent falls (05/22/10, 05/27/10, and 06/04/10) of which one (1) resulted in a [MEDICAL CONDITION] and hospitalization . She had a physician's orders [REDACTED]. The kardex indicated the use of both mat and sensor alarms, but neither of these devices was included on the care plan. There are three (3) interventions in the care plan that were not on the kardex for the nursing assistants to see and use. They were: ""Frequent observation; Assure adequate lighting in the room; and Maintain clear pathways."" -- b) During an interview with the DON at 8:30 a.m. on 07/16/10, she acknowledged, after reviewing the records of the residents above, that there was a lack of coordination in the care plan process resulting in all planned necessary interventions either not being on the care plan and/or not being communicated to the direct caregivers via the kardex.",2014-07-01
11254,GRANT COUNTY NURSING HOME,515151,27 EARLY AVENUE,PETERSBURG,WV,26847,2009-08-31,225,E,1,0,GJK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to: (1) immediately report allegations of abuse and/or neglect to the appropriate State agencies within twenty-four (24) hours of the allegation being received for two (2) of twelve (12) sampled residents; and (2) failed to report an allegation of abuse and/or a bruise of unknown origin to the appropriate State agencies for two (2) of twelve (12) sampled residents. Resident identifiers: #89, #11, #50, and #107. Facility census: 104. Findings include: a) Resident #89 A review of the facility's records of self-reported allegations of abuse / neglect and the medical record of Resident #89 revealed this resident alleged a nursing assistant was being ""rude to her"" and making unkind remarks. This statement was made to the assistant director of nurses (ADON) on 08/24/09, but it was not reported to OHFLAC until 08/28/09, after the investigation had been done and the nursing assistant had received a written warning. Both the immediate and the 5-day follow-up reports were filed on that date. During an interview with the ADON at 11:45 a.m. on 08/31/09, she acknowledged the dates were correct and stated her belief that she should not report an allegation until after she checked into it. b) Resident #11 A review of the facility's records of self-reported allegations of abuse / neglect revealed a letter from the daughter of Resident #11 containing numerous allegations of neglect which was received by the director of social services on 08/24/09; however, these allegations were not reported to the appropriate State agencies until 08/28/09, when the investigation was initiated. During an interview with both social workers and the administrator at 11:30 a.m. on 08/31/09, the director of social services stated the dates were correct and the letter was so [MEDICAL CONDITION] that she did not consider reporting the allegations until a phone call containing the same allegations and threats was received on 08/28/09. This was acknowledged by the administrator also. c) Resident #50 A review of an incident report revealed Resident #50 had a ""large tan bruise /c (with) yellow edges to (R) (right) forehead area"", which was found by a nursing assistant and reported to the nurse in charge. The nurse completed an incident report and notified the daughter. The nurse's note, at 9:00 a.m. on 07/08/09, stated the bruised area was of ""unknown origin"". A nurse's note, written on 07/09/09, recorded the status of the bruise, but there was no evidence of an investigation into the cause, and this injury of unknown source was not reported to the appropriate State agencies as required by law. During an interview with the director of nurses (DON) and the administrator at 3:00 p.m. on 08/31/09, they reviewed the form and stated there was no additional documentation, as they had not considered the bruise questionable. The DON assumed that, since a mechanical lift was used to transfer this resident, the resident she had bumped her head on it. d) Resident #107 A review of a complaint report, filed on 07/22/09, revealed Resident #107, who was alert, oriented, and had capacity, alleged during a care plan meeting on that date that on the previous day (07/21/09), one (1) of the nurses was rough and rude to her while administering her medications and ""that her feelings were hurt and she cried several hours."" The care team referred this allegation to the ADON, who interviewed the resident but did not report this allegation of abuse to the appropriate State agencies. During an interview with the ADON and the administrator at 11:45 a.m. on 08/31/09, the ADON agreed the incident should have been reported. .",2014-07-01
11255,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,441,F,1,0,Q89G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control summary report, and staff interview, the facility failed to maintain an effective infection control program that provided the necessary monitoring, trending / tracking, and data analysis necessary to ensure a safe and sanitary resident environment. By failing to ensure these key elements of the program were effective, the facility did not aid in preventing the development and/or transmission of disease and infection. Eight (8) residents developed urinary tract infections (UTIs) that cultured positive with a bacterium present in feces (Eschericia coli or E. coli) from 02/01/10 through 06/15/10. The facility's infection control program did not include measures to identify possible sources / causes of these infections (e.g., improper incontinence care) or to track / trend in an effort to identify patterns of infections and control the spread of infection within the facility. This had the potential to affect more than an isolated number of residents in the facility. Resident identifiers: #50, #39, #26, #14, #48, #1, #40, and #43. Facility census: 49. Findings include: a) Residents #50, #39, #26, #14, #48, #1, #40, and #43 1. Review of the facility's infection control program found staff had identified the presence of E. coli in the urine of eight (8) residents from 02/01/10 through 06/15/10. - Resident #50's urine cultured positive for E. coli on 02/19/10. - Resident #39's urine cultured positive for [DIAGNOSES REDACTED] pneumoniae and E. coli on 02/22/10. - Resident #26's urine cultured positive for E. coli on 03/10/10. - Resident #14's urine cultured positive for E. coli on 03/17/10. - Resident #48's urine cultured positive for E. coli on 03/24/10. - Resident #1's urine cultured positive for E. coli on 05/11/10. - Resident #40's urine cultured positive for E. coli on 05/16/10. - Resident #43's urine cultured positive for E. coli on 06/04/10. According to the facility's infection control nurse (Employee #3), Residents #1 and #40 received staff assistance assistance with toilet use but performed cleansing / personal hygiene independently, and Resident #50 had an indwelling catheter the entire time he resided at the facility. According to the residents' most recent minimum data set (MDS) assessments, Residents #39, #26, #48, and #43 were totally dependent on staff for toilet use, including cleansing / personal hygiene after toilet use. Resident #14 was independent with both toilet use and cleansing / personal hygiene. -- 2. An interview with the director of nursing (DON - Employee #1), on 06/16/10 at 10:00 a.m., revealed the facility had changed their infection program during the month of February 2010, adopting the affiliated hospital's infection control program. At this time, the facility no longer tracked and analyzed for patterns with respect to the locations of residents with infections and/or the frequency of infections involving specific organisms. -- 3. In an interview on 06/16/10 at approximately 10:00 a.m., Employee #3 related she had served in the role as infection control nurse since January 2010. She acknowledged she has not received any formal training but goes to the hospital adjacent to the facility for some education, and she contacts the infection control nurse at the hospital when she has questions. She reported having plans to attend infection control training in October 2010. On 06/16/10 at approximately 11:00 a.m., Employee #3 showed proof that inservice education was provided to staff on both perineal care (cleansing after toilet use or incontinence) and handwashing. The inservice on perineal care occurred on 02/25/10. The handwashing inservice occurred on 06/03/10. No additional inservicing on perineal care had occurred after 02/25/10, although six (6) new E. coli UTIs occurred after this date, and four (4) of these six (6) affected residents were dependent upon staff for personal hygiene after toilet use. -- 4. According to the medical records person (Employee #65) on 06/16/10, the facility started using new infection control logs in February 2010. She stated that, prior to February 2010, each infectious organism was always identified on the infection control log. Employee #65 stated that the licensed practical nurses (LPNs) are now filling out the infection control logs on their own. They are supposed to fill out the sheet in its entirety whenever they get a physician's orders [REDACTED]. Prior to February, the facility was tracking their infections and identifying the infectious organism. At times, the physician does not order a culture and, therefore, the infectious organism is not identified. According to Employee #65, every three (3) months, the DON will request the logs and analyze the data. -- 5. The DON, when interviewed on 06/16/10 at approximately 12:00 p.m., said, initially, the facility had implemented a root cause analysis form and used the infection control nurse as a resource. The hospital infection control nurse told Employee #3 that this root cause analysis was not necessary. The DON confirmed that infections had not been tracked since February. The DON indicated that, previously, the infection control logs were reviewed during the quarterly quality assurance meeting. The DON stated the new form was designed to bring the facility more in line with the requirements specified at F441 and to give the LPNs more responsibility. The DON questioned the issue of residents who wanted to toilet themselves, such as Resident #14. She indicated she felt she could do education with Resident #14 in order to ensure the resident performs personal hygiene in a manner so as not to contaminate her urinary tract. (Note that, according to Employee #3, Residents #1 and #40 also performed their own personal hygiene after toilet use, although they received staff assistance on and off the commode.) -- 6. The DON and the administrator both confirmed, in an interview on 06/16/10 at approximately 3:30 p.m., that they had changed their infection control practices (including the way they gathered and tracked information) after the changes made to the guidance to surveyors by the Centers for Medicare & Medicaid Services. They indicated they felt they were trying to do things in a better way, but they agreed the new way was not capturing the information needed to ensure the facility was identifying and controlling infections. .",2014-07-01
11256,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,281,E,1,0,Q89G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, review of the facility's standing orders, staff interview, 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 assure that licensed practical nurses (LPNs) provided nursing care within their scope of practice. The facility utilized standing physician's orders [REDACTED]. This had the potential to affect more than an isolated number of residents. Facility census: 49. Findings include: a) Standing orders Review of the physician's standing order sheet found the following: 1. Tylenol ""Tylenol two tabs every 4hrs (4 hours) by mouth as needed for headache, joint pain , or temperature elevation (100 degrees F). May use rectal suppository for 650 mg if unable to take by mouth. ..."" This order did not specify the strength of the Tylenol to be given orally, only the number of tablets to be administered. -- 2. Interventions for constipation ""M.O.M. (Milk of Magnesia) 30ml with Cascara 10ml every 3 days by mouth as needed for residents with c/o (complaint of) constipation."" ""Check for impaction two times weekly if no bowel movement is recorded for three consecutive days. Fleets enema every day if needed after resident is checked for impaction."" ""[MEDICATION NAME] ([MEDICATION NAME]) 10mg suppository rectally once daily for constipation."" There were no clear instructions for choosing one of the options over another, leaving the choice to the discretion of the licensed nurse to utilize any of three options at anytime. There were also no instructions for assessment of the resident's bowel sounds or when to notify physician if one (1) or more of these options do not promote bowel elimination within a specified period of time. -- 3. [MEDICATION NAME] ""[MEDICATION NAME] plain 10ml every 4hours (sic) by mouth as needed for 10 days for simple cough without fever. Notify physician if cough persists."" There was no time frame / parameter directing the licensed nurse when to contact the physician with the exception of ""if cough persists"". -- 4. Suctioning ""Suction orally or nasally as needed for congestion. ..."" There were no guidelines for choosing one (1) route over another when suctioning. --- b) An interview with the director of nursing (Employee #1) and the administrator (Employee #68), on the evening of 06/16/10, confirmed the standing physician's orders [REDACTED]. Both the director of nursing and the administrator agreed this practice could create negative outcomes for the residents. --- c) Review of the ""Guidelines for Delegation"", on page 12, found: ""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 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."" .",2014-07-01
11257,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,327,G,1,0,Q89G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain proper hydration and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to her comprehensive admission assessment with an ARD of 08/29/09, she weighed 140# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. [DIAGNOSES REDACTED]. According to an abbreviated quarterly assessment with an ARD of 11/28/09, Resident #43 weighed 131# with a height of 60 and was receiving a therapeutic diet and a dietary supplement. The assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. Further record review revealed, on 12/07/09, the registered dietitian (RD) noted on her recommendation form to the physician that the resident had poor intake by mouth and a significant weight loss. At this time, the RD recommended 2 ounces of a sugar-free nutritional supplement three (3) times a day. Documentation in the resident's clinical record reflected the RD had seen Resident #43 after 12/07/09 but made no further recommendations. According to an abbreviated quarterly assessment with an ARD of 02/21/10, she weighed 126# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. At this time, the assessor indicated there was a significant weight loss, but no chewing or swallowing problems were noted. On 03/23/10, Resident #43 was started on nectar thickened liquids. On 04/04/10, a nurse documented that a nursing assistant reported Resident #43 was coughing and was observed drinking regular (not thickened) water from a sink. On 04/05/10, a nurse documented the resident was not eating. Resident #43 was sent to the hospital at 1:30 p.m. on 04/05/10, for evaluation of questionable stroke. The nursing transfer / discharge note stated, ""Resident has a history of stroke, family concerned, stated they thought her mouth was drawn, physician was notified of transfer."" Additional documentation in this note stated the resident had been exhibiting difficulty swallowing for several weeks. Resident #43 returned to the facility later that same evening (on 04/05/10 at 7:30 p.m.) with [DIAGNOSES REDACTED]. On 04/06/10, a nurse documented the resident was found drinking melted ice (not thickened) from the bucket holding a bottle of thickened liquid at bedside. Resident #43 was sent to the hospital on [DATE] for a modified [MEDICATION NAME] swallowing study. The impression from the swallowing study noted: ""At this time patient displayed a functional oro-pharyngeal phase swallow."" The recommendations from the swallowing study were: ""1. Consider continuation of a regular diet with regular thin liquids. ""2. Full upright position with all oral intake and remain upright for 30 minutes following. ""3. Monitor pt. (patient) for signs of aspiration. ""4. May consider beginning each meal with ice or lemon swab to stimulate swallow or 'wake up' swallow. ""5. Clinical correlation is recommended."" On 04/08/10, Resident #43 was taken off of thickened liquids, put back on regular thin liquids, and ordered sugar-free ice cream to stimulate swallow instead of ice as recommended. Nursing documentation, dated 04/21/10, noted Resident #43 refused breakfast and was spitting it out. An RD progress note, dated 04/27/10, noted various lab values that had been obtained, including the following elevated values: serum glucose - 143 (normal range is 64 to 128); blood-urea-nitrogen (BUN) - 41 (normal range is 7 - 20); and creatinine - 1.9 (normal range is 0.8 - 1.4); the elevated BUN and creatinine levels are indicative of impaired renal function, and the elevated BUN, creatinine, and serum glucose levels can also be indicative of dehydration. In the same note, the RD stated the physician was notified of lab values. The RD made no recommendations at this time. On 05/01/10, a nurse documented Resident #43 ""drools food at times pushes tongue forward when eating."" On 05/04/10, a nurse documented Resident #43 got choked at dinner and "" ... was able to cough and clear throat (sic) must have been liquid because resident never coughed anything up."" On 05/06/10, a nurse noted the resident was observed ""sticking tongue to the end of her mouth and pushing food out, holding food before swallowing, letting fluids drool out the sides of her mouth."" On 05/07/10, a nurse documented Resident #43 got ""strangled"" twice on water. On 05/15/10, a nurse recorded the nursing assistant observed Resident #43 was spitting her food out and coughing. According to the next consecutive assessment, a comprehensive assessment addressing a significant change in status with an ARD of 05/23/10, the resident weighed 113# with a height of 60 inches and was now receiving a mechanically altered diet, a therapeutic diet, and a dietary supplement. The assessor indicated there was a significant weight loss, she left twenty-five percent (25%) or more of her food uneaten at most meals, she was on a planned weight change program, and she now had both chewing and swallowing problems. A nursing note, dated 06/04/10 at 10:00 a.m., stated, ""Unable to get sippy cup to mouth. Resident dehydrated, poor skin turgor."" A physician's telephone order was obtained to send the resident to the hospital emergency room for evaluation, and the resident's responsible party was notified at 9:55 a.m. on 06/04/10. The nursing transfer / discharge note, dated 06/04/10 at 10:00 a.m., in the section on the transfer / discharge summary where the nurse briefly describes events leading to transfer, the nurse recorded: ""Decrease in blood pressure, decrease level of consciousness, decrease in cognition, and very dehydrated."" She had also written, ""Resident intake poor."" On 06/04/10, she transferred to an acute care hospital, where she was admitted with provisional [DIAGNOSES REDACTED]. Hospital documentation also noted her lab values included elevated chloride, serum glucose, and serum sodium levels, all of which can be indicative of hypovolemia. According to her resident assessment instruments, Resident #43, and she returned to the nursing facility on 06/08/10. Her Medicare 5-Day assessment, with and ARD of 06/15/10, indicated she now weighed 115# with a height of 59 inches, and the assessor also noted she had chewing and swallowing problems, she had experienced a significant weight loss, and she had been receiving nutrition fluid via a feeding tube and intravenously (IV). Resident #43 remained on IV fluids until the insertion of a feeding tube on 06/15/10. -- 2. Review of Resident #43's physician orders [REDACTED].#43 and her medical power of attorney representative (MPOA) had indicated, during her initial admission beginning on 04/29/08, the desire for intravenous (IV) fluids and a feeding tube for a defined trial period. The POST form was updated on 08/19/09, with the same wishes specified. -- 3. During a telephone interview beginning at 1:00 p.m. on 06/15/10, Resident #43's MPOA indicated she felt good about the care Resident #43 related to her hygiene needs. She said she was not satisfied as far as the care of her health needs; she felt Resident #43's health was continuing to decline. The MPOA stated she had called the facility and spoken with the social worker (Employee #66). She questioned whether Resident #43 had had another stroke, and she asked Employee #66 to have the physician call her to discuss the resident's change in condition. The physician did not contact the MPOA as requested. The MPOA stated no one at the facility had ever discussed the need for a feeding tube until 06/09/10, when she came to a care conference at the facility. -- 4. During an interview with the social worker (Employee #66) on 06/15/10 at 2:00 p.m., she stated she had contacted the physician regarding a feeding tube on 05/22/10, due to the resident's weight loss and poor intake. She said the physician wanted to first try [MEDICATION NAME] to stimulate her appetite before consulting about a feeding tube. According the Employee #66, she contacted the physician again regarding a feeding tube on 06/09/10, and the physician told the social worker to contact the MPOA regarding consult for a feeding tube. .",2014-07-01
11258,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,514,D,1,0,Q89G11,"**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 eleven (11) residents had an accurate and complete medical record. A comparison of documentation of the resident's bowel movements (BMs), recorded in the plan of care kardex (kardex) and the bowel and bladder elimination pattern evaluation (B&B evaluation form) for the period of 03/01/10 through 03/31/10, found significantly conflicting information about the frequency at which she was having BMs, calling into question the accuracy of the BM monitoring upon which the facility staff based a determination of whether to administer medications to treat constipation. Resident identifier: #23. Facility census: 49. Findings include: a) Resident #23 Resident #23's medical record, when reviewed on 06/14/10 at approximately 2:00 p.m. and again on 06/15/10, disclosed this [AGE] year old female was admitted to the facility from a local hospital on [DATE], with [DIAGNOSES REDACTED]. A nursing note completed by the director of nursing (DON) on 02/24/10 at 4:25 p.m. stated, ""(Arrow pointing upward) in geri chair @ (at) bedside states 'pain in stomach goes to back.' Unable to quantify or describe specifically in response to questions. Denies burning, stabbing, knife-like twisting pain. Abd (abdomen) flat, non-distended, normoactive BS (bowel sounds) x 3 quadrants /c (with) hyperactive sounds upper left quad on auscultation. Non-tender to palpation. Denies nausea. Reviewed BM record. Appetite good. Remains calm during assessment. Instructed med (medication) nurse to administer pain med. Skin warm and dry."" Record review revealed the nursing assistants recorded each resident's bowel elimination action on a monthly kardex. The instructions on the kardex directed staff to record both bowel and bladder elimination in the same section of the form for each shift daily; staff was supposed to record each BM by noting the size of the BM as follows: S = Small, M = Medium, L = Large, and D = Diarrhea. A review of the resident's February 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 02/15/10 through 02/28/10, on some days noting that BMs occurred on more than one (1) shift. A review of the resident's March 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 03/01/10 through 03/11/10 (the day she was found to have a fecal impaction). Again, on some days, staff even noted the resident had BMs on more than one (1) shift. Further record review revealed a B&B evaluation form for the period of 03/01/10 through 03/31/10. On this form staff was supposed to, on an hourly basis, circle ""BL"" if the resident were incontinent of bladder and circle ""B"" if the resident were incontinent of bowel. Additionally, each time the resident voids urine or has a BM, staff was to place a check mark in the corresponding column (for ""Voided"" or ""BM"") corresponding to this time it occurred. According to this record, Resident #23 did NOT have BMs on a daily basis in the days leading up to the discovery of the fecal impaction, as had been recorded on the kardex: 03/01/10 - BM at 10:00 a.m. 03/02/10 - BM at 7:00 a.m. 03/03/10 - No BM 03/04/10 - No BM 03/05/10 - BM at 3:00 a.m. 03/06/10 - No BM 03/07/10 - No BM 03/08/10 - BM at 4:00 p.m. 03/09/10 - BM at 8:00 a.m. 03/10/10 - BMs at 7:00 a.m., 11:00 a.m., and 2:00 p.m. In view of the sharp inconsistencies between the information recorded on the kardex and the B&B evaluation form for the same time frame (03/01/10 through 03/10/10), the surveyor could not ascertain which, if either, record accurately reflected Resident #23's bowel elimination activity in the days preceding discovery, via CT scan, of the fecal impaction on 03/11/10. Record review found staff did not accurately and completely fill out the kardex with respect to bowel actions for the months of February, March, April, and June 2010. Staff did not consistently document the number of BMs as they occurred, nor were they consistent in documenting the size of each BM in accordance with the instructions on the form. In an interview on the afternoon of 06/15/10, the director of nursing confirmed the nursing assistants were not completing these forms as required.",2014-07-01
11259,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,309,G,1,0,Q89G11,"**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 eleven (11) sampled residents received the care and services necessary to promote regular bowel elimination and prevent a fecal impaction. Record review revealed Resident #23 received at CT scan of her abdomen and pelvis on 03/11/10, in response to complaints of stomach pain projecting to her back. According to the radiology report dated 03/11/10, the CT scan revealed a ""(l)arge amount of fecal material in the rectosigmoid portion of the colon with fecal impaction."" Further review of the resident's medical record found she was assessed as having hypoactive bowel sounds during her admission nursing assessment on 02/09/10, with no follow-up assessment of her bowel sounds until she complained of abdominal pain on 02/24/10, at which time her bowel sounds were normal in three (3) quadrants and hyperactive in the upper left quadrant of her abdomen. No further assessments of her bowel sounds were documented after this finding, although she continued to complain of (and was medicated for) abdominal pain. A comparison of documentation of the resident's bowel movements (BMs), recorded in the plan of care kardex (kardex) and the bowel and bladder elimination pattern evaluation (B&B evaluation form) for the period of 03/01/10 through 03/31/10, found significantly conflicting information about the frequency at which she was having BMs, calling into question the accuracy of the BM monitoring upon which the facility staff based a determination of whether to administer medications to treat constipation. Even where the two (2) separate documents concurred that no BMs had occurred for three (3) consecutive days, the facility failed to administer medications to promote bowel elimination in accordance with the physician's standing orders. Resident identifier: #23. Facility census: 49. Findings include: a) Resident #23 1. Resident #23's medical record, when reviewed on 06/14/10 at approximately 2:00 p.m. and again on 06/15/10, disclosed this [AGE] year old female was admitted to the facility from a local hospital on [DATE], with [DIAGNOSES REDACTED]. -- 2. According to the admission nursing assessment completed at 4:25 p.m. on 02/09/10, the assessor noted, on a physical assessment of the resident's abdomen, that bowel sounds were present and ""hypoactive"". According to Medline Plus, a service of the U.S. National Library of Medicine and the National Institutes of Health, "" ...Reduced (hypoactive) bowel sounds include a reduction in the loudness, tone, or regularity of the sounds. They indicate a slowing of intestinal activity. ""Hypoactive bowel sounds are normal during sleep, and also occur normally for a short time after the use of certain medications and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation. ..."" (Source: ) Following this finding, there was no evidence of any further assessment of the resident's bowel sounds until the resident complained of stomach pain on 02/24/10. -- 3. A nursing note completed by the director of nursing (DON) on 02/24/10 at 4:25 p.m. stated, ""(Arrow pointing upward) in geri chair @ (at) bedside states 'pain in stomach goes to back.' Unable to quantify or describe specifically in response to questions. Denies burning, stabbing, knife-like twisting pain. Abd (abdomen) flat, non-distended, normoactive BS (bowel sounds) x 3 quadrants /c (with) hyperactive sounds upper left quad on auscultation. Non-tender to palpation. Denies nausea. Reviewed BM record. Appetite good. Remains calm during assessment. Instructed med (medication) nurse to administer pain med. Skin warm and dry."" Review of the February 2010 Medication Administration Record [REDACTED]""C/O (complaint of) constipation."" The next consecutive entry in the nursing progress notes was dated 10:40 a.m. on 03/02/10, indicating the completion of a dietary consult. This entry was followed by another entry at 5:00 p.m. on 03/02/10, noting receipt of orders for [MEDICATION NAME] 20 mg every day and a consult with Physician #2 (a [MEDICATION NAME]). The next consecutive entry in the nursing progress notes, dated 03/04/10 at 8:30 a.m., noted the resident's attending physician (Physician #1) visited the resident and ordered [MEDICATION NAME] 10 mg by mouth thirty (30) to sixty (60) minutes before meals at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Review of the physician's progress note for this visit, dated 03/04/10, found the statement, ""Abd (abdominal) pain unclear etiology."" Review of the March 2010 MAR found a nurse administered MOM at 5:00 p.m. on 03/04/10 for ""constipation"". The next consecutive entry in the nursing progress notes, dated 03/08/10 at 8:30 a.m., noted Physician #2 visited the resident and gave orders for a CT scan of her abdomen and pelvis with oral and intravenous (IV) contrast, a chest x-ray and a urinalysis with culture and sensitivity all to be scheduled for 03/11/10. The next consecutive entry in the nursing progress notes, dated 03/10/10 at 4:40 p.m., noted that staff notified the resident's legal representative of the above ordered diagnostic procedures. The next consecutive entry in the nursing progress notes, dated 03/11/10 at 9:00 a.m., noted the resident was prepped for the CT scan. The next consecutive entry in the nursing progress notes, dated 03/11/10 at 10:40 a.m., indicated the resident had returned from the CT scan and had expelled a large amount of loose stool. The results of the CT scan were noted as having been received and communicated via facsimile to both Physicians #1 and #2 at 1:00 p.m. on 03/12/10. The radiology report, dated 03/11/10, stated, ""Large amount of fecal material in the rectosigmoid portion of the colon with fecal impaction."" At no time after the resident complained of stomach pain on 02/24/10 was there documentation of a nursing assessment of the resident's abdomen to include an assessment of the resident's bowel sounds, prior to the discovery of the fecal impaction on 03/11/10. -- 4. According to Medline Plus, ""A fecal impaction is a large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that it cannot come out of the body. Watery stool from higher in the bowel may move around the mass and leak out, causing soiling or diarrhea."" (Source: ) Also according to Medline Plus, ""Constipation refers to infrequent or hard stools, or difficulty passing stools. Constipation may involve pain during the passage of a bowel movement, inability to pass a bowel movement after straining or pushing for more than 10 minutes, or no bowel movements after more than 3 days. ..."" (Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm) -- 5. Review of Resident #23's medical record found a sheet of physician's standing orders, which included the following: ""M.O.M. (Milk of Magnesia) 30ml (sic) with Cascara 10ml (sic) every 3 days by mouth as needed for residents with c/o (complaint of) constipation."" ""Check for impaction two times weekly if no bowel movement is recorded for three consecutive days. Fleets enema every day if needed after resident is checked for impaction."" ""[MEDICATION NAME] ([MEDICATION NAME]) 10mg suppository rectally once daily for constipation."" -- 6. The nursing note, dated 02/24/10 at 4:25 p.m., indicated the assessing nurse had reviewed the resident's BM record. Record review revealed the nursing assistants recorded each resident's bowel elimination action on a monthly kardex. The instructions on the kardex directed staff to record both bowel and bladder elimination in the same section of the form for each shift daily; staff was supposed to record each BM by noting the size of the BM as follows: S = Small, M = Medium, L = Large, and D = Diarrhea. A review of the resident's February 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 02/15/10 through 02/28/10, on some days noting that BMs occurred on more than one (1) shift. According to the documentation on this kardex, at no time during this period did the resident have three (3) consecutive days with no BM, which would have triggered the need to administer MOM in accordance with the physician's standing orders. According to this record, there was no indication for the need to administer a dose of MOM on 02/24/10. A review of the resident's March 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 03/01/10 through 03/11/10 (the day she was found to have a fecal impaction). Again, on some days, staff even noted the resident had BMs on more than one (1) shift. According to documentation on this kardex, at no time during this period did the resident have three (3) consecutive days with no BM, which would have triggered the need to administer MOM in accordance with the physician's standing orders. According to this record, there was no indication for the need to administer a dose of MOM on 03/04/10. -- 7. Further record review revealed a B&B evaluation form for the period of 03/01/10 through 03/31/10. On this form staff was supposed to, on an hourly basis, circle ""BL"" if the resident were incontinent of bladder and circle ""B"" if the resident were incontinent of bowel. Additionally, each time the resident voids urine or has a BM, staff was to place a check mark in the corresponding column (for ""Voided"" or ""BM"") corresponding to this time it occurred. According to this record, Resident #23 did NOT have BMs on a daily basis in the days leading up to the discovery of the fecal impaction, as had been recorded on the kardex: 03/01/10 - BM at 10:00 a.m. 03/02/10 - BM at 7:00 a.m. 03/03/10 - No BM 03/04/10 - No BM 03/05/10 - BM at 3:00 a.m. 03/06/10 - No BM 03/07/10 - No BM 03/08/10 - BM at 4:00 p.m. 03/09/10 - BM at 8:00 a.m. 03/10/10 - BMs at 7:00 a.m., 11:00 a.m., and 2:00 p.m. In view of the sharp inconsistencies between the information recorded on the kardex and the B&B evaluation form for the same time frame (03/01/10 through 03/10/10), the surveyor could not ascertain which, if either, record accurately reflected Resident #23's bowel elimination activity in the days preceding the discovery, via CT scan, of the fecal impaction on 03/11/10. -- 8. In an interview on 06/16/10 at approximately 12:00 p.m., the DON and a registered nurse (RN - Employee #9) related their belief that staff had acted appropriately and timely by getting Resident #23 an appointment with a [MEDICATION NAME] and having the physician at the facility examine her. -- 9. Following the discovery of the fecal impaction on 03/11/10, review of the resident's bowel elimination activity throughout the remainder of March 2010 (as recorded on both the March 2010 kardex and the B&B evaluation form), found periods when the resident had no BM for three (3) consecutive days when no MOM (or other intervention to promote regular bowel elimination) was administered in accordance with the physician's standing orders: According to the March 2010 kardex, the resident had no BM following the afternoon shift on 03/12/10 until the night shift on 03/15/10 with no interventions (when she was noted to have a small BM), following the night shift on 03/15/10 until the afternoon shift on 03/19/10 (when she was noted to have an ""XLG"" BM), following the afternoon shift on 03/20/10 until the afternoon shift on 03/23/10 (when she was noted to have a small BM), and form the afternoon of 03/25/10 through 03/31/10 (with no BM being recorded on this kardex through the end of the month). According to the March 2010 B&B evaluation form, the resident had no BM from 1:00 p.m. on 03/11/10 until 3:00 a.m. on 03/15/10, from 6:00 a.m. on 03/15/10 until 3:00 p.m. on 03/22/10, and from 2:00 p.m. on 03/27/10 through 11:59 p.m. on 03/31/10, with no interventions. -- 10. Record review found staff did not accurately and completely fill out the kardex with respect to bowel actions for the months of February, March, April, and June 2010. Staff did not consistently document the number of BMs as they occurred, nor were they consistent in documenting the size of each BM in accordance with the instructions on the form. In an interview on the afternoon of 06/15/10, the DON confirmed the nursing assistants were not completing these forms as required. -- 11. Further review of the resident's record found a progress summary note, dated 05/24/10, indicating the resident again complained of abdominal pain. Review of the June 2010 kardex found the resident had no recorded BM from the afternoon of 06/06/10 through the afternoon of 06/15/10. Review of physician's telephone orders revealed an order, dated 06/04/10, for 4 ounces of prune juice to be delivered on the resident ' s breakfast tray everyday when available from dietary. There were no other bowel stimulating interventions provide. A review of the resident's medical record did not reveal any documentation pertaining to consumption of prune juice; therefore, the nursing staff had no way of determining whether the resident consumed the prune juice. The prune juice came with other fluids at the breakfast meal, and the documentation of the resident's consumption prune juice was combined with the total amount of all fluids consumed at any given meal. .",2014-07-01
11260,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-06-17,325,G,1,0,Q89G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain adequate parameters of nutrition and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. According to weight records, Resident #43 weighed 146.8# on 08/19/09; on 06/09/10, she weighed 107#. This represented a 39.8# weight loss over a ten (10) month period. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to her comprehensive admission assessment with an ARD of 08/29/09, she weighed 140# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. [DIAGNOSES REDACTED]. According to an abbreviated quarterly assessment with an ARD of 11/28/09, Resident #43 weighed 131# with a height of 60 and was receiving a therapeutic diet and a dietary supplement. The assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. Further record review revealed, on 12/07/09, the registered dietitian (RD) noted on her recommendation form to the physician that the resident had poor intake by mouth and a significant weight loss. At this time, the RD recommended 2 ounces of a sugar-free nutritional supplement three (3) times a day. Documentation in the resident's clinical record reflected the RD had seen Resident #43 after 12/07/09 but made no further recommendations with respect to her weight loss. According to an abbreviated quarterly assessment with an ARD of 02/21/10, she weighed 126# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. At this time, the assessor indicated there was a significant weight loss, but no chewing or swallowing problems were noted. On 03/23/10, Resident #43 was started on nectar thickened liquids. On 04/05/10, a nurse documented the resident was not eating. Resident #43 was sent to the hospital at 1:30 p.m. on 04/05/10, for evaluation of questionable stroke. The nursing transfer / discharge note stated, ""Resident has a history of stroke, family concerned, stated they thought her mouth was drawn, physician was notified of transfer."" Additional documentation in this note stated the resident had been exhibiting difficulty swallowing for several weeks. Resident #43 returned to the facility later that same evening (on 04/05/10 at 7:30 p.m.) with [DIAGNOSES REDACTED]. Resident #43 was sent to the hospital on [DATE] for a modified [MEDICATION NAME] swallowing study. The impression from the swallowing study noted: ""At this time patient displayed a functional oro-pharyngeal phase swallow."" The recommendations from the swallowing study were: ""1. Consider continuation of a regular diet with regular thin liquids. ""2. Full upright position with all oral intake and remain upright for 30 minutes following. ""3. Monitor pt. (patient) for signs of aspiration. ""4. May consider beginning each meal with ice or lemon swab to stimulate swallow or 'wake up' swallow. ""5. Clinical correlation is recommended."" On 04/08/10, Resident #43 was taken off of thickened liquids, put back on regular thin liquids, and ordered sugar-free ice cream to stimulate swallow instead of ice as recommended. Nursing documentation, dated 04/21/10, noted Resident #43 refused breakfast and was spitting it out. On 05/01/10, a nurse documented Resident #43 ""drools food at times pushes tongue forward when eating."" On 05/06/10, a nurse noted the resident was observed ""sticking tongue to the end of her mouth and pushing food out, holding food before swallowing, letting fluids drool out the sides of her mouth."" On 05/15/10, a nurse recorded the nursing assistant observed Resident #43 spitting her food out and coughing. According to the next consecutive assessment, a comprehensive assessment addressing a significant change in status with an ARD of 05/23/10, the resident weighed 113# with a height of 60 inches and was now receiving a mechanically altered diet, a therapeutic diet, and a dietary supplement. The assessor indicated there was a significant weight loss, she left twenty-five percent (25%) or more of her food uneaten at most meals, she was on a planned weight change program, and she now had both chewing and swallowing problems. A nursing note, dated 06/04/10 at 10:00 a.m., stated, ""Unable to get sippy cup to mouth. Resident dehydrated, poor skin turgor."" A physician's telephone order was obtained to send the resident to the hospital emergency room for evaluation, and the resident's responsible party was notified at 9:55 a.m. on 06/04/10. The nursing transfer / discharge note, dated 06/04/10 at 10:00 a.m., in the section on the transfer / discharge summary where the nurse briefly describes events leading to transfer, the nurse recorded: ""Decrease in blood pressure, decrease level of consciousness, decrease in cognition, and very dehydrated."" She had also written, ""Resident intake poor."" On 06/04/10, she transferred to an acute care hospital, where she was admitted with provisional [DIAGNOSES REDACTED]. Hospital documentation also noted her lab values included elevated chloride, serum glucose, and serum sodium levels, all of which can be indicative of hypovolemia. (See also citation at F327.) Resident #43 returned to the nursing facility on 06/08/10. Her Medicare 5-Day assessment, with and ARD of 06/15/10, indicated she weighed 115# with a height of 59 inches, and the assessor noted she had chewing and swallowing problems, she had experienced a significant weight loss, and she had been receiving nutrition fluid via a feeding tube and intravenously (IV). Resident #43 remained on IV fluids until the insertion of a feeding tube on 06/15/10. -- 2. Review of the resident's weight records, during her stay from 08/19/09 through 06/09/10, revealed the following: 08/19/09 - 146.8# 08/24/09 - 140.0# 09/07/09 - 136.0# 10/06/09 - 135.7# 11/03/09 - 131.1# 12/08/09 - 133.1# 01/04/10 - 126.1# 02/08/10 - 125.6# 03/09/10 - 123.4# 04/05/10 - 118.1# 05/03/10 - 113.0# 05/24/10 - 106.1# 05/30/10 - 105.4# 06/09/10 - 107.0# -- 3. Review of Resident #43's physician orders [REDACTED].#43 and her medical power of attorney representative (MPOA) had indicated, during her initial admission beginning on 04/29/08, the desire for intravenous (IV) fluids and a feeding tube for a defined trial period. The POST form was updated on 08/19/09, with the same wishes specified. -- 4. During a telephone interview beginning at 1:00 p.m. on 06/15/10, Resident #43's MPOA indicated she felt good about the care Resident #43 related to her hygiene needs. She said she was not satisfied as far as the care of her health needs; she felt Resident #43's health was continuing to decline. The MPOA stated she had called the facility and spoken with the social worker (Employee #66). She questioned whether Resident #43 had had another stroke, and she asked Employee #66 to have the physician call her to discuss the resident's change in condition. The physician did not contact the MPOA as requested. The MPOA stated no one at the facility had discussed with her the need for a feeding tube until 06/09/10, when she attended a care conference at the facility. -- 5. During an interview with the social worker (Employee #66) on 06/15/10 at 2:00 p.m., she stated she had first contacted the physician regarding a feeding tube on 05/22/10, due to the resident's weight loss and poor intake. She said the physician wanted to first try [MEDICATION NAME] to stimulate her appetite before consulting about a feeding tube for a defined period. According to her weight records, Resident #43 weighed 113# on 05/03/10, when the social worker approached the physician about a feeding tube. (By this time, the resident had already experienced a weight loss of 27# (19%) in an eight (8) month period.) According the Employee #66, she contacted the physician again regarding a feeding tube on 06/09/10, and the physician told the social worker to contact the MPOA regarding obtaining a consult for a feeding tube. .",2014-07-01
11261,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,157,D,1,0,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, staff interviews, observations, and resident comments, the facility failed to notify the physician of a resident's repeated refusal of [MEDICATION NAME] eye drops (for reduction of elevated pressure in the eyes). The facility also failed to notify the responsible party when a resident was sent out for an appointment at a local hospital for repair of her [MEDICAL TREATMENT] access. Two (2) of thirty-four (34) residents on the Stage II sample were affected. Resident identifiers: #13 and #11. Facility census: 55. Findings include: a) Resident #13 During observation of medication administration pass on 03/08/11 at 8:37 a.m., Employee #21, a registered nurse (RN), took Resident #13's [MEDICATION NAME] eye drops to the bedside. The nurse asked the resident if she wanted to take the eye drops that morning. The resident declined the eye drops, saying she did not need them at that time. The nurse did not ask the resident why she did not want to take the eye drops, nor did she advise the resident the purpose of the drops. (The resident also had orders for natural tears.) - Review of this [AGE] year old woman's medical record found she had [DIAGNOSES REDACTED]. 365.9 - Unspecified [MEDICAL CONDITION] 374.05 - Trichiasis of eyelid without entropion 375.15 - Unspecified tear film insufficiency 366.9 - Unspecified cataract - On 03/15/11 at approximately 3:30 p.m., review of the nursing entries (which reflected the reasons for medications not being administered noted on the electronic Medication Administration Record [REDACTED] - 03/14/11 at 08:52 - ""[MEDICATION NAME] - 1 drop both eyes q (every) day : Refused med."" - 03/13/11 at 09:46 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused med."" - 03/12/11 at 10:09 - ""Patient requested not to have eye drops in."" - 03/08/11 at 08:38 - ""[MEDICATION NAME] - 1 drop both eyes q day : Pt. (patient) refused eye drops states she does not need the right now."" - 03/07/11 at 08:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states it makes her eyes feel funny."" - 02/27/11 at 09:43 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states 'I dont (sic) take them any more."" - 02/25/11 at 09:15 - ""[MEDICATION NAME] - 1 drop both eyes q day : resident refused [MEDICATION NAME] eye drops."" - 02/22/11 at 08:32 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused eye drops states 'I quit taking those they make my eyes worse."" - 02/21/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused med this am (morning)."" - 02/20/11 at 09:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : Resident refused eye drops today."" - 02/12/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused [MEDICATION NAME] eye drops."" - 02/08/11 at 08:20 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refuses [MEDICATION NAME] eye drops."" In January 2011, the [MEDICATION NAME] was held on 01/24/11, 01/23/11, 01/16/11, 01/10/11, and 01/09/11. - A ""Physician's Contact Note"", dated 12/28/11 at 18:25, noted: ""Complaints of eyes burning, refusing [MEDICATION NAME] dye drops, appetite decreased. Dr. ____ in to see resident today."" At that time, the resident was assessed as having [MEDICAL CONDITION] and antibiotic eye drops were ordered. No further evidence was found indicating the physician had been notified of the resident's continued intermittent refusal of the [MEDICATION NAME] eye drops. There was no indication the resident was told the drops were for her [MEDICAL CONDITION]. - Review of the resident's current care plan found no care planning relative to the resident's refusal of the [MEDICATION NAME] eye drops. - Review of information about [MEDICATION NAME] at http://www.[MEDICATION NAME].com/content/index.aspx found: ""[MEDICATION NAME] is indicated for the reduction of elevated intraocular pressure in patients with open-angle [MEDICAL CONDITION] or ocular hypertension ... [MEDICATION NAME] offers easy once-a-day use ... ""[MEDICATION NAME] is an eyedrop that lowers pressure in the eye. You don't usually feel eye pressure, but if it is too high, it can damage the optic nerve and cause vision loss. [MEDICATION NAME] is your partner in the fight against high eye pressure which can lead to [MEDICAL CONDITION]. ..."" - Notification of the physician when a resident refuses medications was discussed with Employee #78 (an RN) at 10:00 a.m. on 03/16/11. She said she thought the resident had to refuse three (3) days in a row before the physician was contacted. Employee #76 (the minimum data set coordinator) was in the room at this time. Employee #76 asked her if it had to be three (3) days before the physician was notified of a resident refusing medications, but Employee #78 said she did not know. -- b) Resident #11 Medical record review for Resident #11, conducted on 03/09/11, revealed Resident #11 received [MEDICAL TREATMENT] on an outpatient basis due to having [MEDICAL CONDITION]. A [MEDICAL TREATMENT] communication sheet, filled out by the [MEDICAL TREATMENT] center on 12/26/10, indicated the physician at the [MEDICAL TREATMENT] center had scheduled the resident to go out to a local hospital on [DATE] for a surgical procedure. A nursing note, dated 12/26/10 at 3:58 p.m., stated, ""Pre/Post [MEDICAL TREATMENT] Weight: Pere (sic) weight -85.1kg. Resident attended [MEDICAL TREATMENT], but they were unable to access her. She was sent back without receiving treatment. She is scheduled to meet with the Doctor in out patient at (name of hospital) to have her Quinton catheter checked. Will be NPO (nothing by mouth) after midnight and will be picked up by (name of ambulance company) at 5:00 a.m."" During an interview on 03/09/11 at approximately 1:00 p.m., the director of nursing (Employee #79) reported she felt the nursing staff at the facility needed to contact the responsible party even if the [MEDICAL TREATMENT] center made the appointment. Resident #11 did not have capacity to understand and make informed health care decisions, and her sorrugate decision-maker was not informed of the appointment. .",2014-07-01
11262,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-03,279,D,1,0,JMN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of six (6) sampled residents with an indwelling Foley urinary catheter who had a history of [REDACTED]. Resident identifier: #32. Facility census: 89. Findings include: a) Resident #32 Observation, from the hallway on 02/28/11 at approximately 4:55 p.m., found Resident #32 lying in bed with his urinary catheter bag lying directly on the carpeted floor in his room. A nurse (Employee #53) and an unidentified nurse aide walked past the resident's room with no intervention. (See also citation at F315.) Review of the medical record revealed this resident had a history of [REDACTED]. Review of his care plan revealed no problem statement or goal related to the recurrent urinary tract infections or the presence or need for a Foley catheter; subsequently, no interventions to address the care and treatment of [REDACTED]. During an interview with the director of nursing, on the afternoon of 03/02/10, she agreed there was no mention of the urinary catheter in the resident's care plan. .",2014-07-01
11263,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-03,315,D,1,0,JMN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, record review, and policy review, the facility failed to provide treatment and services, to one (1) of six (6) sampled residents with an indwelling Foley urinary catheter, to prevent the development of urinary tract infections. Record review revealed no physician's order for the use of [REDACTED]. Additionally, the resident's catheter bag was observed on one (1) occasion lying on the carpeted floor by the resident's bedside, which was contradictory to facility policy. Resident identifier: #32. Facility census: 89. Findings include: a) Resident #32 1. Observation, from the hallway on 02/28/11 at approximately 4:55 p.m., found Resident #32 lying in bed with his urinary catheter bag lying directly on the carpeted floor in his room. A nurse (Employee #53) and an unidentified nurse aide walked past the resident's room with no intervention. At 5:00 p.m., the nurse who was caring for this resident (Employee #94) was summoned to observe the urinary drainage bag lying directly on the floor. She stated Resident #32 was just moved from another room, the drainage bag should have had a covering over it, and the drainage bag was not supposed to touch the floor. She stated she would take care of it. Review of the facility's policy titled ""5.2 Catheter: Indwelling Urinary - Care of"" (revised 11/01/07), on page 2, stated: ""Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor."" 2. Review of the medical record revealed this resident had a history of [REDACTED]. Review of Resident #32's physician orders found no mention of the presence of the Foley catheter or directives for its care. Review of his care plan revealed no problem statement or goal related to the recurrent urinary tract infections or the presence or need for a Foley catheter; subsequently, no interventions to address the care and treatment of [REDACTED]. During an interview with the director of nursing on the afternoon of 03/02/11, she said staff had documented the presence of the catheter and the color of the urine in nursing notes, and she produced copies of nursing notes attesting to this. She also agreed there was no mention of the catheter in the care plan.",2014-07-01
11264,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-31,225,E,1,0,VVFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on record review and staff interview, the facility failed to substantiate the lack of care for two (2) of six (6) sampled residents (#33 and #49) and four (4) random residents (#84, #50, #4, and #73) as neglect. These six (6) residents were found soaked in urine in their beds by nursing staff on the 11:00 p.m. to 7:00 a.m. (11-7) shift at 11:15 p.m. on 03/13/11. One (1) of these residents (#73) reported that she had turned on her call light to summon assistance to the bathroom but the nursing assistant (NA) turned the call light off and left the room without providing any assistance. Several of these residents were fully dressed in their street clothes, and one (1) of them (#50) was still wearing her shoes. All of them were either totally dependent and/or required extensive physical assistance with dressing, toilet use, and/or personal hygiene. The facility's internal investigation identified Employee #92 as the NA having been assigned to care for these six (6) residents care on the 3:00 p.m. to 11:00 p.m. (3-11) shift on 03/13/11. Review of the facility's five-day follow-up reports and interview with the administrator (Employee #1) and director of nursing (DON - Employee #2), on 03/31/11 at 1:00 p.m., found the facility did not substantiate that these residents had been neglected. Resident identifiers: #4, #33, #49, #50, #73, and #84. Facility census: 83. Findings include: a) Residents #4, #33, #49, #50, #73, and #84 Review of the facility's internal investigations into allegations of abuse / neglect revealed six (6) residents - all of whom had been assigned to receive care from the same NA (Employee #92) on the 3-11 shift on 03/13/11 - were found during rounds by the oncoming staff at 11:15 p.m. to be in bed, fully dressed in street clothes, and soaked with urine. 1. Resident #73 Review of an APS reporting form for Resident #73, dated 03/13/11 with Employee #114 (an NA) identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents still fully dressed & soaked in urine. (Resident #73) stated that she had put her light on for bathroom asst. but that the aide had turned the light off & left. She was wet at this time. Review of Resident #73's most recent minimum data set assessment (MDS) with an assessment reference date (ARD) of 01/29/11 revealed this [AGE] year old female required the extensive physical assistance of two (2) or more persons with toilet use, and she was totally dependent on staff for personal hygiene and dressing. 2. Resident #4 Review of an APS reporting form for Resident #4, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on the hall she found several residents still fully dressed & soaked in urine. (Resident #4) was wet & still in her street clothes."" Review of Resident #4's most recent MDS with an ARD of 02/01/11 revealed this [AGE] year old female was totally dependent on staff for dressing, required the extensive physical assistance of one (1) person for personal hygiene, and required the extensive assistance of two (2) or more persons for toilet use. 3. Resident #84 Review of an APS reporting form for Resident #84, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on the 330 hall she noted that several residents still fully dressed and soaked in urine. (Resident #84) was still in her street clothes and was wet & smelled of urine."" Review of Resident #4's most recent MDS with an ARD of 03/11/11 revealed th is [AGE] year old female was totally dependent on one (1) person for dressing, personal hygiene, and toilet use. 4. Resident #50 Review of an APS reporting form for Resident #50, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents on the 330 hall still fully dressed and soaked in urine. (Resident #50) was in her street clothes and was wet."" Review of Resident #50's most recent MDS with an ARD of 02/15/11 revealed this [AGE] year old female was totally dependent on two (2) or more persons for dressing, personal hygiene, and toilet use. 5. Resident #33 Review of an APS reporting form for Resident #33, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents on the 330 hall wet & still fully dressed. (Resident #33) was soaked in urine & had a large bowel movement."" Review of Resident #33's most recent MDS with an ARD of 02/01/11 revealed this [AGE] year old male was totally dependent on one (1) person for dressing and personal hygiene, and he required the extensive physical assistance of one (1) person for toilet use. This resident also had bilateral above knee amputations. 6. Resident #49 Review of an APS reporting form for Resident #49, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents still fully dressed & soaked in urine. (Resident #49) was still in her street clothes & told (Employee #114) that she had put herself to bed."" Review of Resident #49's most recent MDS with an ARD of 01/04/11 revealed this [AGE] year old female required the extensive physical assistance of one (1) person for dressing, toilet use, and personal hygiene. -- b) Review of the facility's internal investigation into these allegations revealed the following employee statements: - A written statement from Employee #114, dated 03/13/11, contained the following (quoted verbatim): ""... 1115 (11:15 p.m.) (Resident #33) rang my co-workers answer the light and changed him, and said he was soaked, and had a large bowel movement and that (Resident #73) rang and wanted to go to bathroom so the assisted her to the potty chair. I started my hall check at 11:30 pm. I went to (Resident #49) first she was fully dressed in street clothes and said she put her self to bed. ... I went down to (Resident #84) her brief was so wet the inner padding was balling up and smelled very bad, she was also fully dressed in street clothes I cleaned her up changed her clothes done peri care and washed he face which had dried food every where, I than went to (Resident #50) she was wet but wasn't as bad as (Resident #84) but had her street clothes on and her shoes, changed her brief and clothes had a co-workers help pull her up and went to (Resident #4) she was fully dressed in street clothes and was wet . (Resident #73) had told me while I was in taking care of the roommate that about 9:00 pm she rang and wanted to go to bathroom the girl just turn off the light and left that's why she was wet."" - A written statement from a licensed practical nurse (LPN - Employee #91), which was not dated, contained the following (quoted verbatim): ""1. (Room number) (name of Resident #49), dry, in bed fully clothed in street clothes. Stated she put herself to bed. 2. (Room number) (name of Resident #50) in bed, wet with street clothes and shoes on. 3. (Room number) (name of Resident #84) in bed with brief so wet that the padding balled up in street clothes. 4. (Room number) (name of Resident #4) in bed in street clothes. 5. (Room number) (name of Resident #73) asking for BR (bathroom) - stated that other girl just turned off my light & left me 11:10 pm. 6. (Room number) (name of Resident #33) called for help. Stated he was soaked 11pm. Night shift CNAs (certified nursing assistants) made me aware of problems above. I was also informed that when night shift came on the CNA from 30 hall was sitting at the 3-11 desk. She did not make the night shift CNAs aware that there had been any problems, or that she may have gotten behind."" - A statement typed by the facility's social worker (Employee #29), recording a conversation she had with Employee #88 (the LPN who was in charge on B wing on 03/13/11 and was Employee #92's supervisor during that shift), contained the following (quoted verbatim): ""Per a conversation with the LPN, (name of Employee #88) regarding the allegations of neglect made against (name of Employee #92) she was not aware of any issues / concerns regarding resident care on the afternoon of 3-13-11."" - A written statement from Employee #92, dated 03/14/11, contained the following (quoted verbatim): ""On 3-11 shift on 03-13-11 I (name of Employee #92) left 3 people in their clothes when I put them to bed. There is more residents on 30 Hall on B-wing than the other halls. I was concerned with getting everyone into bed and cleaned up rather than getting everyone into their night clothes. We only had 3 CNA's so it's hard to ask other people for help when they are busy getting their own residents to bed. I did do a round on my hall around 10 pm and had everyone dry then I started my book work."" According to a Follow Up Summary (undated), ""On 3-13-11 the CNA (name of Employee #114) reported that when she came on duty for the 11:00 - 7:00 shift on the 330 hall she found several residents fully dressed and wet with urine. Upon checking the daily staffing sheets it was noted that (name of Employee #92) was the aide who worked the 330 hall from 3:00 - 11:00. (Employee #92) was placed on suspension pending an investigation into these allegations of neglect. ... Although we feel that this aide needs to receive counseling regarding the above issues, we do not substantiate neglect toward any of the residents in her care. ..."" -- c) In an interview on 03/31/11 at 1:00 p.m., the administrator and DON reported they did not determine that Employee #92 was responsible for neglecting the above residents. They also did not determine who was responsible for the lack of care of these residents, nor did they believe that neglect had occurred. -- d) Review of the facility's policy titled ""1.0 Abuse Prohibition"" (effective 03/01/02) revealed the following: ""Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."" -- e) During an interview on 03/31/11 at 12:00 p.m., the social worker (Employee #29) confirmed the definition for neglect found in the facility's abuse / neglect policy (dated 03/01/02) was not applied in this investigation. -- Part II -- Based on record review and staff interview, the facility failed to report an allegation of neglect for one (1) of six (6) sampled residents (#35) after the resident's family expressed concern that the resident's oxygen delivery tubing was not always in place and her toileting needs were not always met. During an interview with the administrator and DON on 03/31/11 at 1:00 p.m., they confirmed this concern had not been viewed as an allegation of neglect and, consequently, was not reported to State agencies as required by law. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 During a review of the facility's complaint records, a ""Concern Form"" was found regarding Resident #35 dated 02/26/11. The family expressed a concern that the resident's oxygen delivery tubing was not always in place and that her toileting needs were not always met. Written statements were obtained from one (1) registered nurse (RN - Employee #137) and one (1) NA (Employee #77) on 02/26/11. The facility conducted a one-on-one inservice with the RN and NA on 02/26/11. This information was not reported to any State agencies as required by law. In an interview conducted on 03/31/11 at approximately 1:00 p.m., administrator and DON agreed these concerns were not reported to any State agency as required by law. .",2014-07-01
11265,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-31,312,E,1,0,VVFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, review of the facility's internal investigations into allegations of neglect, and staff interview, the facility failed to provide timely assistance with incontinence care and/or toilet use for three (3) of six (6) sampled residents (#35, #33, and #49) and four (4) random residents (#84, #50, #73, and #4). Resident identifiers: #35, #4, #33, #49, #50, #73, and #84. Facility census: 83. Findings include: a) Resident #35 Observation, at 1:40 p.m. on 03/30/11, found Resident #35 sitting at the nurses' station on the South Wing. A subsequent observation, in the resident's room at 1:50 p.m. on 03/30/11, found two (2) nursing assistants providing incontinence care to Resident #35, at which time her incontinence brief was found to be soaked with urine and her wheelchair cushion had pools of urine on its surface. In an interview on 03/31/11 at approximately 1:00 p.m., the administrator (Employee #1) and the director of nursing (DON - Employee #2) were informed of Resident #35's condition at the time of the observations. b) Residents #4, #33, #49, #50, #73, and #84 Review of the facility's internal investigations into allegations of abuse / neglect revealed six (6) residents - all of whom had been assigned to receive care from the same NA (Employee #92) on the 3-11 shift on 03/13/11 - were found during rounds by the oncoming staff at 11:15 p.m. to be in bed, fully dressed in street clothes, and soaked with urine. 1. Resident #73 Review of an APS reporting form for Resident #73, dated 03/13/11 with Employee #114 (an NA) identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents still fully dressed & soaked in urine. (Resident #73) stated that she had put her light on for bathroom asst. but that the aide had turned the light off & left. She was wet at this time. Review of Resident #73's most recent minimum data set assessment (MDS) with an assessment reference date (ARD) of 01/29/11 revealed this [AGE] year old female required the extensive physical assistance of two (2) or more persons with toilet use, and she was totally dependent on staff for personal hygiene and dressing. 2. Resident #4 Review of an APS reporting form for Resident #4, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on the hall she found several residents still fully dressed & soaked in urine. (Resident #4) was wet & still in her street clothes."" Review of Resident #4's most recent MDS with an ARD of 02/01/11 revealed this [AGE] year old female was totally dependent on staff for dressing, required the extensive physical assistance of one (1) person for personal hygiene, and required the extensive assistance of two (2) or more persons for toilet use. 3. Resident #84 Review of an APS reporting form for Resident #84, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on the 330 hall she noted that several residents still fully dressed and soaked in urine. (Resident #84) was still in her street clothes and was wet & smelled of urine."" Review of Resident #4's most recent MDS with an ARD of 03/11/11 revealed th is [AGE] year old female was totally dependent on one (1) person for dressing, personal hygiene, and toilet use. 4. Resident #50 Review of an APS reporting form for Resident #50, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents on the 330 hall still fully dressed and soaked in urine. (Resident #50) was in her street clothes and was wet."" Review of Resident #50's most recent MDS with an ARD of 02/15/11 revealed this [AGE] year old female was totally dependent on two (2) or more persons for dressing, personal hygiene, and toilet use. 5. Resident #33 Review of an APS reporting form for Resident #33, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents on the 330 hall wet & still fully dressed. (Resident #33) was soaked in urine & had a large bowel movement."" Review of Resident #33's most recent MDS with an ARD of 02/01/11 revealed this [AGE] year old male was totally dependent on one (1) person for dressing and personal hygiene, and he required the extensive physical assistance of one (1) person for toilet use. This resident also had bilateral above knee amputations. 6. Resident #49 Review of an APS reporting form for Resident #49, dated 03/13/11 with Employee #114 identified as the reporter, revealed the following: ""When the 11-7 shift aide came on duty she found several residents still fully dressed & soaked in urine. (Resident #49) was still in her street clothes & told (Employee #114) that she had put herself to bed."" Review of Resident #49's most recent MDS with an ARD of 01/04/11 revealed this [AGE] year old female required the extensive physical assistance of one (1) person for dressing, toilet use, and personal hygiene. 7. When interviewed at 1:00 p.m. on 03/31/11, the administrator and DON agreed these residents did not receive an acceptable level of incontinence care. .",2014-07-01
11266,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-31,328,D,1,0,VVFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to provide proper treatment and services for respiratory care for two (2) of six (6) sampled residents. Resident #33's nasal cannula was not positioned properly to ensure the resident received the full measure of oxygen (O2), and the rate at which the O2 was being delivered was less than that which had been ordered by the physician. Resident #35 was in a wheelchair receiving O2 via a portable oxygen tank; observation of the gauge on the portable tank found it registered empty. Resident identifiers: #33 and #35. Facility census: 83. Findings include: a) Resident #33 Record review revealed Resident #33 was an [AGE] year old male resident with multiple medical [DIAGNOSES REDACTED]. Observation, on 03/31/11 at 10:00 a.m., found Resident #33 in bed with O2 being delivered via nasal cannulae supplied by an oxygen concentrator. Further observation found the resident's nasal cannula was incorrectly positioned with only one (1) prong of the cannula in the left nare. Additionally, observation of the oxygen concentrator found the delivery rate was set at 1.5 L/min. Review of the physician's orders [REDACTED]. In an interview on 03/31/11 at 10:05 a.m., the licensed practical nurse who was providing care for residents on North wing (Employee #93) was questioned about the rate at which Resident #33 was to receive O2. Employee #93 reviewed the resident medical record and confirmed the O2 should have been delivered at a rate of 2 L/min, not 1.5 L/min. Following re-adjustment of the O2 delivery rate and proper positioning of the nasal cannula, this surveyor requested the resident's O2 saturation level (O2 sat) be tested with a pulse oximeter. The results of the pulse oximeter revealed the resident's oxygen saturation level was low at 87-88%. Observation of Resident #33 at that time found him to be alert and able to carry on appropriate conversation. The resident's color was not cyanotic, with no shortness of breath observed. Resident #33, during the course of this observation, demanded this surveyor leave his room and stop looking at him. The resident also stated he would not wear an O2 mask when it was brought to him by the Employee #93. A follow-up interview with Employee #93 verified the resident did refuse to wear the mask she brought to his bedside to improve his O2 sat. On 03/31/11 at 10:40 a.m., a registered nurse (RN - Employee #71) informed this surveyor the resident's O2 sat had raised to 97%. In an interview at 1:00 p.m. on 03/31/11, the director of nursing (DON - Employee #2) confirmed the resident's O2 status should be checked by nurses throughout every shift. -- b) Resident #35 During the initial tour on 03/30/11 at 1:40 p.m., observation found Resident #35 sitting in a wheelchair at the South Wing nurses' station; the resident had a nasal cannula in place. On inspection, the oxygen tank flow rate was set at 2 L/min and the oxygen gauge needle was at the bottom of the red area, indicating the tank was empty. When this was brought to the attention of a licensed practical nurse (LPN - Employee #111), the LPN stated, ""We need to get her on her concentrator."" The LPN transported the resident to her room and connected the nasal cannula tubing to the oxygen concentrator at a rate of 2 L/min. The pulse oximeter reading was 96-97% with a pulse rate of 71. On 03/31/11 at 11:45 a.m., the LPN stated, ""The tank on (Resident #35) was not empty. I felt the air coming out of the nasal cannula."" This was not reported until twenty-two (22) hours after direct observation found the oxygen gauge needle indicating the contrary. At approximately 1:00 p.m. on 03/31/11, the administrator (Employee #1) stated the LPN had come to her yesterday (03/30/11) and informed her that the oxygen tank was not empty. .",2014-07-01
11267,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-31,441,D,1,0,VVFS11,". Based on observation, policy and procedure review, and staff interview, the facility failed to ensure staff changed gloves and practiced appropriate hand hygiene after providing incontinence care to one (1) of six (6) sampled residents. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Observation, at 1:50 p.m. on 03/30/11, found two (2) nursing assistants (NAs - Employees #121 and #118) entering the Resident #35's room with a sit-to-stand lift. The NAs wore gloves during the removal of a urine-soaked adult incontinence brief and performance of incontinence care. The NAs then used the sit-to-stand lift, applied a nasal cannula, and prepared the resident for a nap before removing their soiled gloves. Prior to exiting the resident's room, the NAs removed their gloves and washed their hands. Review of the facility's infection control policy titled ""1.5 ADL: Perineal Care (Peri Care)"" with an effective date of 12/01/06 found, under the heading ""Procedure"", the following steps ""1. Gather equipment: ... ""2. Introduce yourself to the resident. ""3. Explain the procedure and provide privacy. ""4. Wash your hands. ""5. Put on gloves. ""6. Assist resident to bathroom. ""7. If present, remove feces ... ""8. Change gloves. ""9. Cleanse perineum with soap, water, and washcloth or perineal cleanser ... ""10. Rinse perineum with water and wipe using washcloth ... ""11. Dry perineum thoroughly using clean towel. ... ""12. Apply protective barrier cream, if indicated. ""13. Assist to apply clean undergarment. ""14. Remove gloves. ""15. Wash hands. ..."" In an interview conducted at approximately 1:00 p.m. on 03/31/11, the administrator (Employee #1) and the director of nursing (DON - Employee #2) agreed the NAs did not follow the facility's infection control policy and procedure with respect to glove changes and hand hygiene.",2014-07-01
11268,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-03-31,282,D,1,0,VVFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review and staff interview, the facility failed to provide care and services for one (1) of six (6) sampled residents in accordance with the comprehensive plan of care. Resident #33 had a physician's orders [REDACTED]. Review of the resident's current comprehensive care plan also found an intervention directing staff to administer O2 to the resident at a rate of 2 L/min. Observation, on 03/31/11 at 10:00 a.m., found the resident was receiving O2 at a rate of only 1.5 L/min, contrary to the physician's orders [REDACTED]. Resident identifier: #33. Facility census: 83. Findings include: a) Resident # 33 Record review revealed Resident #33 was an [AGE] year old male resident with multiple medical [DIAGNOSES REDACTED]. Observation, on 03/31/11 at 10:00 a.m., found Resident #33 in bed with O2 being delivered via nasal cannulae supplied by an oxygen concentrator. Further observation found the resident's nasal cannula was incorrectly positioned with only one (1) prong of the cannula in the left nare. Additionally, observation of the oxygen concentrator found the delivery rate was set at 1.5 L/min. Review of the physician's orders [REDACTED]. In an interview on 03/31/11 at 10:05 a.m., the licensed practical nurse who was providing care for residents on North wing (Employee #93) was questioned about the rate at which Resident #33 was to receive O2. Employee #93 reviewed the resident medical record and confirmed the O2 should have been delivered at a rate of 2 L/min, not 1.5 L/min. Review of the resident's comprehensive care plan (with a review date of 02/22/11) disclosed an intervention to provide Resident #33 with O2 at a rate of 2 L/min to address his respiratory problem. Staff failed to provide services to Resident #33 in accordance with his plan of care. .",2014-07-01
11269,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-03-30,225,D,1,0,FLVW11,". Based on record review, resident interview, and staff interview, the facility failed to immediately report to State officials and thoroughly investigate allegations of abuse / neglect involving two (2) of six (6) sampled residents who made complaints against a certified nursing assistant (CNA). Resident identifiers: #46 and #125. Facility census: 125. Findings include: a) Residents #125 and #46 Review of the facility's internal complaint files found two (2) residents (#46 and #125) reported complaints to staff about a CNA (Employee #22) whom they believed was not taking her time in caring for them. 1. Resident #125 According to a Resident / Family Concern / Grievance form dated 03/11/11, Resident #125 complained that Employee #22 ""moves too quickly or seems rushed when caring for her."" Documentation in Section II of the form stated, ""Spoke with the CNA - the CNA was given a verbal warning."" Resident #125, when interviewed on 03/30/11 at 12:35 p.m., said the CNA would ""get you up, put your clothes on you, but did not bathe you off or comb your hair. This happened every time she took care of me."" 2. Resident #46 According to a Resident / Family Concern / Grievance form dated 02/28/11, Resident #46 complained that the same CNA ""moves too quickly while providing care."" Documentation in Section II of the form stated (quoted as written), ""Spoke with the CNA - about the concern - and CNA instructed to slow down with care and assist /c (with) Residents needs - Educational given to Employee."" Resident #46, when interviewed on 03/30/11 at 1:00 p.m., said Employee #22 ""handles patients too rough and does not ask how I want things done."" According to Resident #46, when Employee #22 cares for her, she does not receive a partial bath in the morning, and the resident has to give herself a partial bath at night. -- b) These two (2) complaints about care issues with the same CNA were received by the facility within two (2) weeks of each other; however, there was no evidence of a thorough investigation by the facility to determine what care the CNA was not providing to the residents. -- c) An interview with facility administrator, on 03/30/11 at 11:00 a.m., found Employee #22 did receive a disciplinary action and re-education in response to these complaints; however, the facility did not report these allegations against Employee #22 to the State nurse aide registry. .",2014-07-01
11270,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-03-30,312,E,1,0,FLVW11,". Based on resident interview, record review, and staff interview, the facility failed to ensure residents received a full bath or shower twice weekly, in accordance with the posted shower schedule. This occurred for six (6) of eight (8) sampled residents whose bathing records were reviewed. Resident identifiers: #2, #8, #48, #25, #36, and #46. Facility census: 125. Findings include: a) Resident #46 Resident #46 was interviewed on 03/29/11 at 3:45 p.m. and said she did not always get her showers. According to the facility's shower schedule for March 2011, Resident #46 was scheduled to receive showers (or full baths in lieu of showers) on 03/02/11, 03/05/11, 03/09/11, 03/12/11, 03/16/11, 03/19/11, 03/23/11, and 03/26/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and ADL sheets, with the administrator and the DON, revealed Resident #46 did not receive showers or full baths on 03/02/11, 03/05/11, 03/12/11, 03/19/11, and 03/26/11, five (5) of eight (8) scheduled times. -- b) Resident #48 According to the facility's shower schedule for March 2011, Resident #48 was scheduled to receive showers (or full baths in lieu of showers) on 03/01/11, 03/04/11, 03/08/11, 03/11/11, 03/15/11, 03/18/11, 03/22/11, 03/25/29, and 03/29/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and ADL sheets, with the administrator and the DON, revealed Resident #48 did not receive a shower or full bath on 03/04/11, 03/15/11, and 03/18/11, three (3) of the nine (9) scheduled shower days in March. -- c) Resident #2 According to the facility's shower schedule for March 2011, Resident #2 was to receive showers (or full baths in lieu of showers) on 03/03/11, 03/07/11, 03/10/11, 03/14/11, 03/17/11, 03/21/11, 03/24/11, and 03/28/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and activities of daily living (ADL) sheets, with the administrator and the director of nursing (DON), revealed Resident #2 did not receive showers or full baths on 03/07/11 or 03/10/11, two (2) of the eight (8) scheduled shower days in March. -- d) Resident #25 Resident #25, when interviewed on 03/29/11 at 4:30 p.m., said she did not always get her showers. According to the facility's shower schedule for March 2011, Resident #25 was scheduled to receive showers (or full baths in lieu of showers) on 03/02/11, 03/05/11, 03/09/11, 03/12/11, 03/16/11, 03/19/11, 03/23/11, and 03/26/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and ADL sheets, with the administrator and the DON, revealed Resident #25 did not receive a shower or full bath on 03/02/11 or 03/23/11, two (2) of the eight (8) scheduled shower days in March. -- e) Resident #36 According to the facility's shower schedule for March 2011, Resident #36 was scheduled to receive showers (or full baths in lieu of showers) on 03/03/11, 03/07/11, 03/10/11, 03/14/11, 03/17/11, 03/21/11, 03/24/11, and 03/28/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and ADL sheets, with the administrator and the DON, revealed Resident #36 did not receive a shower or full bath on 03/03/11 or 03/24/11, two (2) of the eight (8) scheduled shower days in March. -- e) Resident #8 According to the facility's shower schedule for March 2011, Resident #8 was scheduled to receive showers (or full baths in lieu of showers) on 03/03/11, 03/07/11, 03/10/11, 03/14/11, 03/17/11, 03/21/11, 03/24/11, and 03/28/11. On 03/30/11 at 11:00 a.m., review of the resident's shower / bathing sheets and ADL sheets, with the administrator and the DON, revealed Resident #8 did not receive a shower or full bath on 03/14/11, one (1) of the eight (8) scheduled shower days in March.",2014-07-01
11271,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-10-22,157,D,1,0,LT0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and interview with the treating physician, the facility failed to promptly notify the resident's physician and legal representative of a significant change in the physical condition and deterioration in health of one (1) of three (3) sampled residents. Resident identifier: #31. Facility census: 58. Findings include: a) Resident #31 Review of Resident #31's medical record found this [AGE] year old female resident suffered from dysphagia and required nectar consistency fluids. Further review found she had a [DIAGNOSES REDACTED]. The resident was determined to lack the capacity to understand and make medical decisions, and a legal representative (Family #1) was serving as her surrogate decision-makker for all medical decisions. On 09/14/10 at 3:23 p.m., a nurse recorded in the nursing notes that blood was observed in the resident's urine. The treating physician was notified, and a urinalysis with culture and sensitivity was ordered, and the resident was ordered Bactrim DS. The resident received her first dose of Bactrim DS at 9:00 p.m. on 09/14/10. A subsequent note nursing, dated 09/15/10 at 7:20 a.m., documented the resident had decreased level of consciousness (LOC). According to an interview with the director of nursing (DON - Employee #71) on 10/22/10 at 12:15 p.m., the resident's weight was 130#. At 30 cc per kg, the resident would require 1776 cc of fluid each day. Review of the intake and output records found the resident only consumed 1020 cc on 09/13/10, 1100 cc on 09/14/10, 890 cc on 09/15/10, and no (0) cc on 09/16/10. Review of the nursing notes found an entry by a registered nurse (RN - Employee #68), dated 09/16/10 at 8:35 a.m., documenting the resident had no urinary output on the night shift. In the section of the nursing note entitled ""Physician contact"" was documented ""N/A"" (not applicable). In the section entitled ""Responsible party notification"" was documented also ""N/A"". The next nursing note, dated 1:55 p.m. on 09/16/10, documented that the physician on-call was notified of the family's request to transport Resident #31 to the emergency room for further evaluation. An interview with Family #1 (Resident #31's legal representative), at 10:10 a.m. on 10/20/10, revealed the facility did not contact her concerning the decline in her mother's medical condition. Family #1 stated she did not become aware of her mother's critical condition until she was called by a relative who was visiting the resident on the afternoon of 09/16/10. She stated that, had the facility notified her at any time, she would have requested that her mother be sent to the hospital. An interview with the licensed practical nurse (LPN - Employee #61) who worked the day shift of 09/16/10 was conducted via telephone at 1:45 p.m. on 10/21/10. She verified that a family member came in close to lunch time and asked her how Resident #31 was doing. She stated she told this family member that the resident was not doing very ""good"" and she couldn't get her to eat or drink anything. Employee #61 stated this visiting family member called Family #1 (the resident's legal representative). She stated that the legal representative came into the facility and decided to send the resident to the hospital. An interview with the treating physician, on the afternoon of 10/21/10, revealed the physician expected to be notified of any resident displaying a decreased level of consciousness and no urinary output. The facility failed to assure prompt notification was made to the treating physician and the legal representative when this resident's health status declined. The failure to notify as required caused a delay in necessary medical treatment for [REDACTED].) .",2014-07-01
11272,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-10-22,309,G,1,0,LT0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, review of hospital records, and interview with the treating physician, the facility failed to obtain timely medical intervention for one (1) of three (3) sampled residents who exhibited decreased fluid intake, decreased level of consciousness, and no urinary output. This failure resulted in harm to Resident #31 who was transferred to the hospital at the family's request and subsequently was admitted for inpatient treatment of [REDACTED]. Resident identifier: #31. Facility census: 58. Findings include: a) Resident #31 Review of Resident #31's medical record found this [AGE] year old female resident suffered from dysphagia and required nectar consistency fluids. Further review found she had a [DIAGNOSES REDACTED]. The resident was determined to lack the capacity to understand and make informed medical decisions, and a legal representative (Family #1) was serving as her surrogate decision-maker for all medical decisions. On 09/14/10 at 3:23 p.m., a nurse recorded in the nursing notes that blood was observed in the resident's urine. The treating physician was notified, and a urinalysis with culture and sensitivity was ordered, and the resident was ordered Bactrim DS. The resident received her first dose of Bactrim DS at 9:00 p.m. on 09/14/10. A subsequent note nursing, dated 09/15/10 at 7:20 a.m., documented the resident had decreased level of consciousness (LOC). Review of the resident's nutritional assessment, dated 02/16/10, found the resident weighed 160.6 pounds (#) at that time and required 2190 cc of fluids each day (calculated as 30 cc per kilogram (kg)). According to an interview with the director of nursing (DON - Employee #71) on 10/22/10 at 12:15 p.m., the resident's weight was 130#. At 30 cc per kg, the resident would require 1776 cc of fluid each day to maintain fluid balance. Review of the intake and output records found the resident only consumed 1020 cc on 09/13/10, 1100 cc on 09/14/10, 890 cc on 09/15/10, and no (0) cc on 09/16/10. Review of the nursing notes found an entry by a registered nurse (RN - Employee #68), dated 09/16/10 at 8:35 a.m., documenting the resident had no urinary output on the night shift. In the section of the nursing note entitled ""Physician contact"" was documented ""N/A"" (not applicable). In the section entitled ""Responsible party notification"" was documented also ""N/A"". The next nursing note, dated 1:55 p.m. on 09/16/10, documented that the physician on-call was notified of the family's request to transport Resident #31 to the emergency room for further evaluation. An interview with Family #1 (Resident #31's legal representative), at 10:10 a.m. on 10/20/10, revealed the facility did not contact her concerning the decline in her mother's medical condition. Family #1 stated she did not become aware of her mother's critical condition until she was called by a relative who was visiting the resident on the afternoon of 09/16/10. She stated that, had the facility notified her at any time, she would have requested that her mother be sent to the hospital. An interview with the licensed practical nurse (LPN - Employee #61) who worked the day shift of 09/16/10 was conducted via telephone at 1:45 p.m. on 10/21/10. She verified that a family member (not Family #1) came in to the facility close to lunch time and asked her how Resident #31 was doing. Employee #61 stated she told this family member that Resident #31 was not doing very ""good"" and she couldn't get her to eat or drink anything. Employee #61 stated this family member called Family #1 (the resident's legal representative), who came to the facility and decided to send the resident to the hospital. Review of Employee #61's nursing note, dated 1:13 p.m. on 09/16/10, documented the resident's nutritional supplement was withheld ""due to lethargic, will not swallow at this time"". A subsequent note, written by Employee #68 (the 09/15/10 night shift RN) on 09/16/10 at 1:55 p.m., documented the following, ""Resident with decreased LOC and decreased V/S (vital signs). Dr. on call notified of families (sic) request for transport to ER (emergency room ) for further evaluation. Send to ER for further evaluation."" A review of Resident #31's hospital record found the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician ordered intravenous fluid replacement of 5% [MEDICATION NAME] and water to run at a rate of 125 cc per hour. The resident's blood urea nitrogen was 116 mg/dl (normal 7.0 to 18.0 ml/dl), and her creatinine level was 6.0 ml/dl (normal 0.5 to 1.1 ml/dl). An interview with the treating physician, on the afternoon of 10/21/10, revealed the physician expected to be notified of any resident displaying a decreased level of consciousness and no urinary output.",2014-07-01
11273,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,309,K,1,0,LVTE11,". Based on observation, staff interview, review of the facility's list of items to be kept on the crash cart, and review of facility documents, the facility failed to ensure an assembled, readily available suction machine was present in the event of a choking emergency. A facility licensed practical nurse (LPN - Employee #56) brought the crash cart from the nursing station to the room of a resident found to be nonresponsive (Resident #28). Employee #56 was observed to be unable to locate a nasal cannula on the crash cart for administration of oxygen to the resident. It was further noted that the crash cart did not contain a suction machine in the event this resident required suctioning to clear his airway. Following the transportation of Resident #28 to the hospital, Employee #56 was asked to locate a suction machine for use in a choking emergency. Employee #56 searched the drawers of the crash cart, the clean utility room, and the nursing storage room without locating a suction machine. With the assistance of the records information systems clerk (Employee #47) and a member of environmental services (Employee #46), an unassembled suction machine was located in a drawer in the dining room. Seven and one-half (7.5) minutes elapsed before staff could locate a suction machine in the building. The facility identified fourteen (14) residents with swallowing problems and/or who were fed by gastrostomy tube with a facility census of fifty-eight (58) residents. Residents #24, #21, #23, #44, #33, #20, #9, #32, #10, #26, #17, #22, #43, and #56 were placed at risk of serious injury or death from choking should they aspirate food or fluids without a suction machine assembled, readily available, and all staff having knowledge of its location. The administrator was notified that the inability of staff to locate a suction machine in a timely manner placed the fourteen (14) residents with swallowing difficulties in immediate jeopardy of injury or death in the event of a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. Resident identifiers: #24, #21, #23, #44, #33, #20, #9, #32, #10, #26, #17, #22, #43, and #56. Facility census: 58. Findings include: a) During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto his bed and called for oxygen. Employee #56 was observed to search through the drawers of the crash cart and open two (2) bags of oxygen tubing without locating a nasal cannula. A staff member was heard to state, ""Where's my oxygen?"", when Employee #56 ran to the clean utility room to obtain a nasal cannula. Following transportation of the resident to the hospital, Employee #56 was asked, at 2:55 p.m., to locate a suction machine. Employee #56 immediately went to the crash cart and searched through the drawers without locating a suction machine. She then entered the clean utility room and searched the shelves without locating a suction machine. She then walked up the A-wing hallway, past the dining room, to the service hallway and opened the door to a room labeled nursing storage. She was searching this room for a suction machine when a records information systems clerk (Employee #47) entered the room and asked Employee #56 if she was looking for a suction machine. Employee #56 stated that she was looking for a suction machine for the crash cart. Employee #47 stated that suction machines were on the crash carts in the dining room and in the activities room. Employee #56 stated she did not know about suction machines in the dining room or the activities room but needed one (1) for the crash cart. Employee #47 asked Employee #56 if she checked the bottom drawer of the crash cart. Employee #56 stated that she had looked and there was no suction machine. A members of the environmental services staff (Employee #46) approached and stated that a suction machine was in the dining room and the activities room. He located an unassembled suction machine in a drawer in the dining room at 3:02 p.m., a total of seven and one-half (7.5) minutes after the first request was made for the location of a suction machine. Employee #46 was then asked to locate the suction machine in the activities room. He entered the activities room, pointed to an empty section of counter and stated, ""It should be right there."" There was no suction machine located in the activity room at that time. -- At 3:05 p.m., nursing staff members present at the nursing station were asked for the list of items to be kept on the crash cart. The staff members stated the list was kept in the top drawer of the crash cart. All the drawers of the crash cart were searched with no list being located. At 3:15 p.m., the director of nursing (DON) was asked to provide the list of items to be kept on the crash cart. She was unable to provide one and stated that she would look for it. This surveyor located the list in a stack of folders on top of a shelf in the nursing station at 3:40 p.m. The nursing staff members confirmed this was the list used for the crash cart. Review of the document entitled ""Crash Cart Contents"" found the following information: ""Top Of Cart - Extra Back Board (1) Suction Machine (1) Nebulizer (1) Adult Manual Resuscitator with Mask (1)..."". At 3:45 p.m. on 09/15/10, the administrator was informed that the facility placed residents in immediate jeopardy of injury or death by the failure to ensure that a suction machine was kept assembled and readily available for use during a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. -- The administrator was asked to provide the facility's policy related to choking episodes. At 10:00 a.m. on 09/15/10, he provided a document from the nursing procedural manual, Section IV (issue date 01/15/93) entitled ""Emergency Procedures General"". Review of the document found the following: ""A. Purpose ""1. To provide a mechanism for assuring that emergency services are available to all residents, staff or visitors in time of emergency... ""d) Inability to breathe due to choking... ""B. Equipment... ""3. Suction -- machine. ""C. Procedure... ""2. a. Position resident to facilitate breathing: place an airway in the resident's mouth; suction as needed;..."". .",2014-07-01
11274,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,492,F,1,0,LVTE11,". Based on staff interview, review of the facility's numbered list employees, and review of payroll records, the facility failed to assure the dietary department provided services in compliance with all applicable State regulations. The facility failed to obtain the services of a qualified dietary manager to oversee the daily operations of the dietetic service in accordance with 64CSR13 (the nursing home licensure rule). This deficient practice had the potential to affect all residents residing in the facility. Facility census: 58. Findings include: a) On 09/16/10 at 10:30 a.m., a request was made to speak with the dietary manager, to obtain a list of residents who regularly eat in their room. Employee #33 provided the list and was identified as being the acting dietary supervisor. Review of the numbered list of employees provided by the facility found that Employee #33 held the title of dietary services assistant and Employee #37 was identified as the dietary services supervisor. The administrator was asked, on the morning of 09/16/10, if Employee #33 was a certified dietary manager. He stated Employee #33 was not certified and was taking the place of Employee #37 while she was on maternity leave. He stated Employee #37 had been absent since the last of August 2010 and was unable to determine how long she would remain absent. Review of Employee #37's payroll records found her to be absent as of 08/20/10. Review of 64CSR13-8.15.a.3. found the following: ""The dietary manager, under the direction of the dietitian, is responsible for the daily operation of the dietetic service."" Review of 64CSR13-8.15.a.2.A. through C. of the nursing home licensure rule found the following: ""A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following: ""- A dietetic technician, registered by the American Dietetic Association; ""- A certified dietary manager, as certified by the Dietary Manager's Association; or ""- A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management."" The facility provided no evidence that a qualified dietary manager was present to oversee the daily operations of the dietetic department. .",2014-07-01
11275,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,441,F,1,0,LVTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of infection control records, observation, staff interview, and facility policy review, the facility failed to ensure its infection control program was maintained under which it investigates, controls and prevents nosocomial urinary tract infections (UTIs). This deficient practice affected fourteen (14) of fifty-eight (58) facility residents. The facility failed to conduct an investigation to determine causal factors related to the large number of UTIs in the facility and placed all facility residents at risk of infection. Resident identifiers: #55, #50, #40, #53, #35, #58, #48, #29, #5, #17, #30, #39, #52, and #59. Facility census: 58. Findings include: a) Residents #55, #50, #40, #53, #35, #58, #48, and #29 Review of facility's infection control logs, on the afternoon of 09/20/10, revealed Residents #55, #50, #40, #53, #35, #58, #48, and #29 contracted a nosocomial UTI during the month of July 2010. Observation of incontinence care for an uncircumcised male (Resident #4), on 09/20/10 at 2:20 p.m., found the nursing assistant (NA - Employee #16) utilizing a soapy washcloth to cleanse the resident's pubis. She then made one (1) downward stroke with the washcloth toward the resident's urethra. Employee #16 did not retract the resident's foreskin to cleanse this area. This practice placed Resident #4 at risk of contracting a UTI from the contaminated washcloth utilized to first cleanse his pubis. Failing to first cleanse the resident's meatus and area under the foreskin, prior to cleansing the pubis, introduced organisms to the resident's urethra and placed him at risk of infection. The director of nursing (DON - Employee #66) was advised of the above observation and provided a policy on perineal care at 3:00 p.m. on 09/20/10. Review of the perineal care policy (revised 05/01/06), under the section entitled ""Steps in the Procedure"", found the following: ""10. For a male resident:... b. Wash perineal area starting with the urethra and working outward... (1) Retract foreskin of the uncircumcised male."" Employee #66 was asked for evidence that staff members had been inserviced on proper perineal care, as this is a common source of UTIs. She provided evidence of an inservice for perineal care dated 07/23/09, as being the last inservice given on this topic. When asked, on 09/21/10 at 11:05 a.m., for evidence that the facility conducted an investigation into the causal factors related to the nosocomial UTIs for July 2010, the DON could provide no evidence of any investigation conducted by the facility. -- b) Residents #5, #17, #30, #39, #52, and #59 Further review of the facility's infection control logs found that the six (6) residents identified above contracted nosocomial UTIs requiring the use of antibiotics in the month of August 2010. -- c) As of 09/21/10, the facility could provide no evidence to reflect an investigation had been conducted into the causal factors related to fourteen (14) facility residents requiring medical treatment for [REDACTED]. Additionally, the facility failed to assure that nursing staff was provided appropriate training and monitoring related to the provision of perineal care. .",2014-07-01
11276,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,241,D,1,0,LVTE11,". Based on random observation and staff interview, the facility failed to ensure one (1) of five (5) sampled residents was provided care in a manner which indicated respect and dignity. Resident identifier: #14 Facility census: 58. Findings include: a) Resident #14 During random observation of the resident environment on 09/20/10 at 1:45 p.m., Resident #14 was heard to call for a licensed practical nurse (LPN - Employee #52) very loudly and repetitively. Employee #52 was observed to enter the resident's room and exit a short time later. Employee #52 walked by in the resident hallway and muttered, ""It took her all day to figure that one out. Too bad she'll forget it in a half hour."" The administrator was immediately informed of the incident and agreed the statement made by the LPN was not appropriate. .",2014-07-01
11277,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,520,F,1,0,LVTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of infection control records, observation, staff interview, and facility policy review, the facility failed to ensure the quality assessment and assurance (QAA) committee developed and implemented appropriate plans of action to correct a quality deficiencies, of which its members should have been aware, in the area of nosocomial urinary tract infections (UTIs) contracted by residents in the facility during the months of July and August 2010. A total of fourteen (14) of fifty-eight (58) facility residents contracted nosocomial UTIs during the months of July and August 2010. This deficient practice had the potential to affect all facility residents currently residing in the facility. Resident identifiers: #55, #50, #40, #53, #35, #58, #48, #29, #5, #17, #30, #39, #52, and #59. Facility census: 58. Findings include: a) Residents #55, #50, #40, #53, #35, #58, #48, and #29 Review of facility infection control logs, on the afternoon of 09/20/10, found Residents #55, #50, #40, #53, #35, #58, #48, and #29 contracted a nosocomial UTI during the month of July 2010. Observation of incontinence care for an uncircumcised male (Resident #4), on 09/20/10 at 2:20 p.m., found a nursing assistant (NA - Employee #16) utilized a soapy washcloth to cleanse the resident's pubis. She then made one (1) downward stroke with the washcloth toward the resident's urethra. Employee #16 did not retract the resident's foreskin to cleanse this area. This practice placed Resident #4 at risk of contracting a UTI from the contaminated washcloth utilized to first cleanse his pubis. Failing to first cleanse the resident's meatus and area under the foreskin, prior to cleansing the pubis, introduced organisms to the resident's urethra and placed him at risk of infection. The director of nursing (DON - Employee #66) was advised of the above observation and provided a policy on perineal care at 3:00 p.m. on 09/20/10. Review of the perineal care policy (revised 05/01/06), under the section entitled ""Steps in the Procedure"", found the following: ""10. For a male resident:... b. Wash perineal area starting with the urethra and working outward... (1) Retract foreskin of the uncircumcised male."" Employee #66 was asked for evidence that staff members had been inserviced on proper perineal care, as this is a common source of UTIs. She provided evidence of an inservice for perineal care dated 07/23/09, as being the last inservice given on this topic. When asked, on 09/21/10 at 11:05 a.m., for evidence that the facility conducted an investigation into the causal factors related to the nosocomial UTIs for July 2010, the DON could provide no evidence of any investigation conducted by the facility. - b) Residents #5, #17, #30, #39, #52, and #59 Further review of the facility's infection control logs found the residents identified above contracted nosocomial UTIs requiring the use of antibiotics in the month of August 2010. - c) As of 09/21/10, the facility could provide no evidence to reflect an investigation had been conducted into the causal factors related to fourteen (14) facility residents requiring medical treatment for [REDACTED]. Additionally, the facility failed to assure that nursing staff were provided appropriate training and monitoring related to the provision of perineal care. - d) The DON and the administrator (Employee #68) stated, on the afternoon of 09/21/10, that the facility's QAA committee meets at the end of every month. When asked to provide evidence that the QAA committee developed an appropriate plan of action to correct the pattern of nosocomial UTIs during the months of July and August 2010, neither was able to provide evidence that the QAA committee had acted on this matter.",2014-07-01
11278,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-09-22,490,K,1,0,LVTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, staff interviews, and review of 64CSR13 (the Nursing Home Licensure Rule), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and dietary services, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable of the location of an assembled suction machine ready-for-use in the event of a medical emergency; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; and presented the potential for more than minimal harm to all residents related to the facility's failure to procure the services of a qualified dietary manager during the extended absence of the dietary department supervisor. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 58. Findings include: a) Findings of immediate jeopardy During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto his bed and called for oxygen. Employee #56 was observed to search through the drawers of the crash cart and open two (2) bags of oxygen tubing without locating a nasal cannula. A staff member was heard to state, ""Where's my oxygen?"", when Employee #56 ran to the clean utility room to obtain a nasal cannula. Following transportation of the resident to the hospital, Employee #56 was asked, at 2:55 p.m., to locate a suction machine. Employee #56 immediately went to the crash cart and searched through the drawers without locating a suction machine. She then entered the clean utility room and searched the shelves without locating a suction machine. She then walked up the A-wing hallway, past the dining room, to the service hallway and opened the door to a room labeled nursing storage. She was searching this room for a suction machine when a records information systems clerk (Employee #47) entered the room and asked Employee #56 if she was looking for a suction machine. Employee #56 stated that she was looking for a suction machine for the crash cart. Employee #47 stated that suction machines were on the crash carts in the dining room and in the activities room. Employee #56 stated she did not know about suction machines in the dining room or the activities room but needed one (1) for the crash cart. Employee #47 asked Employee #56 if she checked the bottom drawer of the crash cart. Employee #56 stated that she had looked and there was no suction machine. A members of the environmental services staff (Employee #46) approached and stated that a suction machine was in the dining room and the activities room. He located an unassembled suction machine in a drawer in the dining room at 3:02 p.m., a total of seven and one-half (7.5) minutes after the first request was made for the location of a suction machine. Employee #46 was then asked to locate the suction machine in the activities room. He entered the activities room, pointed to an empty section of counter and stated, ""It should be right there."" There was no suction machine located in the activity room at that time. -- At 3:05 p.m., nursing staff members present at the nursing station were asked for the list of items to be kept on the crash cart. The staff members stated the list was kept in the top drawer of the crash cart. All the drawers of the crash cart were searched with no list being located. At 3:15 p.m., the director of nursing (DON) was asked to provide the list of items to be kept on the crash cart. She was unable to provide one and stated that she would look for it. This surveyor located the list in a stack of folders on top of a shelf in the nursing station at 3:40 p.m. The nursing staff members confirmed this was the list used for the crash cart. Review of the document entitled ""Crash Cart Contents"" found the following information: ""Top Of Cart - Extra Back Board (1) Suction Machine (1) Nebulizer (1) Adult Manual Resuscitator with Mask (1)..."". At 3:45 p.m. on 09/15/10, the administrator was informed that the facility placed residents in immediate jeopardy of injury or death by the failure to ensure that a suction machine was kept assembled and readily available for use during a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. (See citation at F309 for additional details.) -- b) Infection control 1. Residents #55, #50, #40, #53, #35, #58, #48, and #29 Review of facility's infection control logs, on the afternoon of 09/20/10, revealed Residents #55, #50, #40, #53, #35, #58, #48, and #29 contracted a nosocomial UTI during the month of July 2010. Observation of incontinence care for an uncircumcised male (Resident #4), on 09/20/10 at 2:20 p.m., found the nursing assistant (NA - Employee #16) utilizing a soapy washcloth to cleanse the resident's pubis. She then made one (1) downward stroke with the washcloth toward the resident's urethra. Employee #16 did not retract the resident's foreskin to cleanse this area. This practice placed Resident #4 at risk of contracting a UTI from the contaminated washcloth utilized to first cleanse his pubis. Failing to first cleanse the resident's meatus and area under the foreskin, prior to cleansing the pubis, introduced organisms to the resident's urethra and placed him at risk of infection. The director of nursing (DON - Employee #66) was advised of the above observation and provided a policy on perineal care at 3:00 p.m. on 09/20/10. Review of the perineal care policy (revised 05/01/06), under the section entitled ""Steps in the Procedure"", found the following: ""10. For a male resident:... b. Wash perineal area starting with the urethra and working outward... (1) Retract foreskin of the uncircumcised male."" Employee #66 was asked for evidence that staff members had been inserviced on proper perineal care, as this is a common source of UTIs. She provided evidence of an inservice for perineal care dated 07/23/09, as being the last inservice given on this topic. When asked, on 09/21/10 at 11:05 a.m., for evidence that the facility conducted an investigation into the causal factors related to the nosocomial UTIs for July 2010, the DON could provide no evidence of any investigation conducted by the facility. - 2. Residents #5, #17, #30, #39, #52, and #59 Further review of the facility's infection control logs found that the six (6) residents identified above contracted nosocomial UTIs requiring the use of antibiotics in the month of August 2010. - 3. As of 09/21/10, the facility could provide no evidence to reflect an investigation had been conducted into the causal factors related to fourteen (14) facility residents requiring medical treatment for [REDACTED]. Additionally, the facility failed to assure that nursing staff was provided appropriate training and monitoring related to the provision of perineal care. (See citation at 441 for additional details.) -- c) Dietary department On 09/16/10 at 10:30 a.m., a request was made to speak with the dietary manager, to obtain a list of residents who regularly eat in their room. Employee #33 provided the list and was identified as being the acting dietary supervisor. Review of the numbered list of employees provided by the facility found that Employee #33 held the title of dietary services assistant and Employee #37 was identified as the dietary services supervisor. The administrator was asked, on the morning of 09/16/10, if Employee #33 was a certified dietary manager. He stated Employee #33 was not certified and was taking the place of Employee #37 while she was on maternity leave. He stated Employee #37 had been absent since the last of August 2010 and was unable to determine how long she would remain absent. Review of Employee #37's payroll records found her to be absent as of 08/20/10. Review of 64CSR13-8.15.a.3. found the following: ""The dietary manager, under the direction of the dietitian, is responsible for the daily operation of the dietetic service."" Review of 64CSR13-8.15.a.2.A. through C. of the nursing home licensure rule found the following: ""A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following: ""- A dietetic technician, registered by the American Dietetic Association; ""- A certified dietary manager, as certified by the Dietary Manager's Association; or ""- A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management."" The facility provided no evidence that a qualified dietary manager was present to oversee the daily operations of the dietetic department. (See citation at F492 for additional details.) .",2014-07-01
11279,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-03-31,441,D,1,0,MX0D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and policy review, the facility failed to follow its own infection control policy, as evidenced by not initiating contact precautions immediately when a resident tested positive for Clostridium difficile (C. diff), a contagious infectious organism. Resident #60 began having diarrhea on 02/10/10; the resident's stool tested positive for [DIAGNOSES REDACTED] on 02/15/10, but the facility did not begin contact precautions isolation until 02/17/10. This was evident for one (1) of eight (8) sampled residents and had the potential to affect other residents on the A Hall, as well as staff and visitors. Resident identifier: #60. Facility census: 60. Findings include: a) Resident #60 Review of physician's orders [REDACTED]. Review of nursing notes revealed standing orders were initiated on 02/10/10 at 4:00 p.m., for an ounce of [MEDICATION NAME] (an antidiarrheal medication) to be given after every loose stool for up to four (4) doses in a twelve (12) hour period; also initiated was a clear liquid diet for twenty-four (24) hours due to diarrhea. Review of the February 2010 medication administration record (MAR) revealed the resident received thirteen (13) doses of [MEDICATION NAME] from 8:00 a.m. on 02/10/10 through 6:00 p.m. on 02/15/10. Nursing notes, dated 02/11/10 at 4:55 p.m., revealed a family member of the resident was concerned about skin irritation due to loose stools. A nursing assessment found the resident had red irritation to the scrotum, bilateral groins, and buttock, and the nurse received an order from the physician for a medicated barrier paste to use every shift until healed. Nursing notes, dated 02/13/10, revealed the physician on-call was notified of the resident's diarrhea, and orders were given for a [DIAGNOSES REDACTED] stool culture. Because it was a weekend, the lab, via telephone on 02/13/10, told nursing staff to refrigerate the specimen and it would be picked up on the following Monday (02/15/10). Review of the medical record revealed a lab report, dated 02/15/10, identifying that Resident #60 was positive for [DIAGNOSES REDACTED] [MEDICATION NAME] and [DIAGNOSES REDACTED] toxin A/B. The laboratory interpretation was that the resident was ""infected with a toxigenic strain of [DIAGNOSES REDACTED]icile"". Nursing notes, dated 02/15/10 at 4:00 p.m., noted the lab results were positive for [DIAGNOSES REDACTED] [MEDICATION NAME] and toxin A/B, and the resident would begin [MEDICATION NAME] 500 mg orally three (3) times daily for fourteen (14) days due to [DIAGNOSES REDACTED] colitis. The nurse notified the family, and they decided to keep the resident in the same room, because ""he is the only resident using the bathroom in that room duplex"". Review of physician's orders [REDACTED]. diff colitis. The nurse who received the order signed the physician's orders [REDACTED]. The physician signed and dated the order form on 02/15/10. Upon receipt of the results of this lab, the facility did not initiate contact precautions for Resident #60 to prevent the spread of [DIAGNOSES REDACTED] to others until two (2) days later (on 02/17/10). Nursing notes, dated 02/17/10 at 8:15 a.m., revealed the director of nursing (DON) obtained new orders from the physician to place the resident in contact precautions until completion of [MEDICATION NAME] therapy or until signs and symptoms of the active [DIAGNOSES REDACTED] infection resolved. Standard precautions as well as contact precautions were then implemented, staff was inserviced on precautions, signage was placed on the room door instructing visitors to report to the nurse's station before entering the room, dietary and environmental services were notified, and education was provided to all departments and staff. Review of the facility's policy and procedure for Clostridium difficile revealed that residents who are colonized and symptomatic are to be placed on Contact Precautions. Interview with the director of nursing (DON), on 03/31/10 at 11:15 a.m., revealed she was informed of the resident's positive [DIAGNOSES REDACTED] results on 02/17/10, and immediately began contact precautions and staff education. She said the nurse who received the order to begin [MEDICATION NAME] on 02/15/10 thought, since the resident was the only one using the toilet in his room, that contact precautions were not needed. The DON said she educated the nurse on the facility's infection control policy. She said the resident's roommate did not get [DIAGNOSES REDACTED], nor did any staff or other residents in the facility. (This was verified by review of the facility's infection tracking records.)",2014-07-01
11280,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-03-31,241,D,1,0,MX0D11,". Based on observation and staff interview, the facility failed to promote care for residents in an environment that enhanced each resident's dignity. Observations of the dining room, at three (3) separate meals on three (3) different days, revealed a petite resident trying to feed herself while seated in a wheelchair at a table that was too high for her to eat in a dignified manner. This was evident for one (1) of eight (8) sampled residents. Resident identifier: #44. Facility census: 60. Findings include: a) Resident #44 1. During the evening meal in the dining room on 03/29/10 at 5:15 p.m., observation found Resident #44 sitting at a table in her wheelchair, spilling food onto her cardigan sweater as she tried to feed herself. Resident #44 was petite, and range of motion deficits of her neck did not allow her to sit with her head held high and erect. The table was at the height of her nose and chin as she sat in her wheelchair, and when her neck was bent, she was only about eye level with her food. 2. Observation of the evening meal, on 03/30/10, found Resident #44 asleep in her wheelchair with her head bent down toward her chest. The table was again too high, and her food was hardly touched. In an interview on 03/30/10 at 5:10 p.m., the licensed social worker (LSW) agreed the table was too high for the resident, and she spoke of another table she could move her to that might be lowered more. She spoke with the resident and tried to rouse her to complete her meal. These findings were discussed with the director of nursing at 12:45 p.m. on 03/31/10. 3. Observation during the noon meal, on 03/31/10 at 12:50 p.m., found Resident #44 was sitting at the same table in her wheelchair in the dining room and not attending to her meal. The seating arrangement posted on the wall in the dining room still listed her as sitting at the same table. During an interview conducted at this time, the LSW said she found another table yesterday that could be lowered a little more, and she had made changes in the seating arrangements yesterday to move Resident #44 to the lower table. She then relocated the resident to the smaller table, which was only about one (1) inch lower than her usual table. The social worker spoke of other possible options, such as a physical therapy evaluation to see if a built-up wheelchair cushion would be practical and safe during meals or ordering a shorter table and seating her and a couple other petite residents together. .",2014-07-01
11281,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2010-02-12,323,D,1,0,71J511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure interventions and adequate supervision were provided to prevent falls for one (1) of three (3) residents reviewed for falls. Resident #39, who had a previous history of a fall from the bed with injury, had been assessed as being at high risk for falls and had planned interventions including the application of bed / chair alarms and a low bed with mats. Following a hospitalization , the facility failed to continue the safety interventions consistent with the resident's history to reduce the risk of falls and injury, and the resident sustained [REDACTED]. Resident identifier: #39. Facility census: 60. Findings include: a) Resident #39 Medical record review, on 02/12/10, disclosed this [AGE] year old male resident had been admitted to the facility from the hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of nursing notes, dated 07/20/09, revealed the resident had bed and chair alarms to alert staff of his attempts to transfer without assistance and half side rails on each side of the bed to assist with bed mobility. This resident was described as being alert, confused, but able to answer simple questions. Following the resident's admission to the facility, nursing recorded the resident as dependent on staff for all activities of daily living, including transfer and bed mobility. Observation of this resident, on 02/12/10 at 11:00 a.m., found the resident was alert, answered simple questions, and was capable of some independent movement in the bed. Review of incident / accident reports found the resident had fallen from his bed at 1:15 p.m. on 08/13/09. The resident sustained [REDACTED]. Further review of the medical record found the resident had been transferred to the hospital for treatment of [REDACTED]. A fall risk assessment upon re-admission from the hospital, dated 11/19/09, identified the resident as being at high risk for falls, having scored ""10"" on the assessment. Further review of the incident / accident reports revealed the resident had again fallen from the bed at 3:20 p.m. on 01/11/10. This report indicated the resident sat up on the side of the bed then fell to the floor on his left side. The report also indicated the resident complained of left hip pain and was sent to the hospital for evaluation, but he was negative for any fractures. Interview with the director of nursing (DON - Employee #44), on 02/12/10 at 1:30 p.m., revealed that, following this accident on 08/13/09, the physician ordered the bed to be in the low position at all times and floor mats to be applied both sides of the bed. The DON acknowledged that, when the resident was readmitted to the facility from the hospital on [DATE], the bed / chair alarm, low bed, and floor mats had not been re-ordered and were not being used. The DON confirmed the facility had failed to implement interventions and supervision, consistent with the resident's history, to reduce the risk of falls and injury.",2014-07-01
11282,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2010-09-01,225,D,1,0,NING11,". Based on a review of the facility's self-reported allegations of abuse / neglect, a review of the facility's grievance / complaint records, and staff interview, the facility failed to assure all allegations of neglect were reported to the appropriate agencies in accordance with State law. Two (2) of four (4) sampled grievance / complaint records contained allegations of neglect that were not reported. Resident identifiers: #3 and #59. Facility census: 57. Findings include: a) Resident #3 On 09/01/10 at approximately 10:00 a.m., review of the facility's grievance / complaint records revealed that, on 08/31/10, the facility received an e-mail communication from the facility's corporate office discussing a complaint made regarding Resident #3's care. Based on this e-mail, the social worker (Employee #20) filled out a grievance / complaint record on 08/31/10. The record stated, ""Dgtr. (daughter) expressed concern that (Resident #3's name) teeth are not getting brushed daily and is not being offered."" Measures taken to resolve this issue included the facility posting this concern on their communication board, and the director of nursing (DON) speaking with licensed practical nurses (LPNs) and registered nurses (RNs) about the concern. On 09/01/10 at approximately 2:00 p.m., the administrator and social worker were interviewed regarding this issue. The social worker indicated the facility had considered reporting this as an allegation of neglect. However, after consulting with their corporate representatives, they elected not to report the issue. The social worker stated, since the resident had not suffered any negative impacts related to the concerns, they did not feel the issue constituted an allegation of neglect. The administrator also confirmed that the facility had not reported the issue as an allegation of neglect. - b) Resident #59 On 08/04/10, the facility filled out a grievance / complaint record regarding Resident #59. The record stated, ""C/O (complained of) changing clothes not done since Saturday, shave on daily basis, catheter bag on floor, legs over off bed when entered room."" The action taken by facility stated, ""Communication to nurses reason / issues and resident decline, needing more care (sic)."" The record also stated the resident was given a complete bath, shaved, and his clothes were changed on 08/04/10. On 09/01/10 at approximately 3:00 p.m., the administrator indicated the facility had not reported this issue as an allegation of neglect. She stated Resident #59 had passed away and received hospice services prior to his death. She also commented that the individual who made the complaint had not visited the resident regularly and did not know his condition had deteriorated. On 09/01/10 at approximately 4:00 p.m., the social worker and administrator agreed to report the issues involving Residents #3 and #59 as allegations of neglect. .",2014-07-01
11283,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2010-09-01,514,C,1,0,NING11,". Based on a review of activities of daily living (ADL) flow charts, medical record review, and staff interview, the facility failed to ensure each resident's medical record was complete and accurate. Four (4) of four (4) sampled residents' ADL flow charts contained incomplete documentation. Resident identifiers: #15, #39, #53, and #3. Facility census: 57. Findings include: a) Residents #15, #39, #53, and #3 On 09/01/10, the August 2010 ADL flow charts were reviewed for Residents #15, #39, #53 and #3. The section titled personal care / oral hygiene contained blanks where the nurse aides had not completed their documentation to verify that care had been rendered. - Resident #15's August 2010's ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/14/10, and 08/27/10. - Resident #53's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/31/10. - Resident #3's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/27/10, 08/29/10, and 08/30/10. - Resident #39's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/14/10, 08/27/10, 08/30/10, and 08/31/10. On 09/01/10 at approximately 3:00 p.m., the director of nursing agreed these blanks needed filled in and acknowledged that, sometimes, the nurse aides forget to complete their documentation.",2014-07-01
11284,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2010-08-03,441,D,1,0,OFKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, policy review, and staff interview, the facility failed to assess and record all urine culture results in order to effectively track and control the spread of infectious organisms. Two (2) of eight (8) residents on the current sample were affected. Resident identifiers: #20 and #29. Facility census: 53. Findings include: a) Resident #20 Record review revealed laboratory results, dated 05/05/10, indicating a positive urine culture for two (2) infectious organisms that were not tracked and recorded in the facility's infection control program. The infectious organisms were Proteus mirabilis and [DIAGNOSES REDACTED] pneumoniae. Laboratory results, dated 06/29/10, revealed a positive urine culture for two (2) infectious organisms (Hapnia alvei and Methicillin-resistant Staphylococcus aureus or MRSA), but only one (1) infectious organism (MRSA) was tracked and recorded in the facility's infection control program. -- b) Resident #29 Record review revealed laboratory results, dated 06/15/10, indicating a positive urine culture for three (3) infectious organisms that were not tracked and recorded in the facility's infection control program. The infectious organisms were Pseudomonas aeruginosa, Pseudomonas aeruginosa #2, and [MEDICATION NAME] faecalis. -- c) Review of the facility infection control policy and procedure found a policy title ""1.2 Infection Control Outcome Surveillance and Reporting (revision date 02/01/10). Stated within the policy and procedure were found the following processes: ""1. Identify all infections."" ""2. Report all infections to Infection Control Coordinator."" -- d) An interview with the infection control coordinator (Employee #28),on 08/03/10 at 3:20 p.m., revealed she did not have urine culture results for 05/05/10 and 06/29/10 on file anywhere in her infection control logs for Resident #20. She did have urine culture results dated 06/29/10, revealing the presence of MRSA, and the resident was on transmission-based precautions. Employee #28 also revealed she did not have urine culture results for 06/15/10 on file anywhere in her infection control logs for Resident #29. She stated she obtains information from various sources (such as getting on-line and linking to the local hospital for culture reports) or nursing staff will notify her of culture results. These organisms, therefore, were not included in tracking and trending infection control surveillance due to missing information.",2014-07-01
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
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
11291,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-03-30,272,D,1,0,VSQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and medical record review, the facility failed to ensure side rail assessments were accurate and consistent with current care plans and physician orders. The facility's side rail assessments did not accurately reflect the current care being received by the residents. Three (3) of twenty-two (22) residents had side rail assessments that did not reflect their current side rail usage. Resident identifiers: #15, #30, and #68. Facility census: 81. Findings include: a) Residents #15, #30, and #68 On 03/30/11 at approximately 10:00 a.m., Employee #78 (the director of nursing - DON) provided a list of all residents in the facility who currently had side rails on their beds; the list contained the names of twenty-three (23) residents. The list provided by the DON indicated Resident #15 needed side rails for protection, Resident #30 needed side rails for mobility, and Resident #68 had ? side rails at the head of her bed for mobility. Record review revealed all three (3) of these residents had current physician orders [REDACTED].#68's physician order, dated 10/06/10, stated: ""? Side rails at HOB (head of bed) for bed mobility."" Resident #30's physician order, dated 10/06/10, stated: ""Side rails for mobility."" Resident #15's physician order, dated 10/06/10, stated: ""Side rails for protection."" Upon request, the DON provided a copy of the side rail assessments completed by the facility for each of the twenty-three (23) residents with side rails. The assessments for Residents #15, #30, and #68 indicated they did not require side rails. Resident #30's assessments (dated 06/03/09, 06/05/09, 08/18/09, 12/13/09, 04/11/09, 07/23/10, 09/22/10, 01/28/11, and 02/24/11) all reflected no side rails were needed. Resident #68's assessments (dated 10/23/09, 01/30/10, 02/18/10, 05/22/10, 08/15/10, and 02/07/10) all reflected the resident did not have side rails. The assessments stated this resident may benefit from side rails but, as of 02/07/10, the assessment showed side rails were not needed. Resident #15's assessments (dated 01/18/09, 04/18/09, 07/18/09, 07/19/10, 09/26/10, and 11/12/10) all reflected side rails as not needed at the present time. On 03/30/11 at approximately 1:30 p.m., the DON stated the residents' care plans all indicated they had side rails on their beds. She reported her belief that the assessments were inaccurate, because they indicated the residents did not have side rails on their beds. .",2014-07-01
11292,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,246,D,1,0,MHV411,". Based on record review and staff interview, the facility failed to provide reasonable accommodations related to the physical environment and staff behaviors for one (1) of ten (10) residents. Review of the facility's call light report revealed, when Resident #78 rang her call bell for assistance on 02/05/11, the call light went unanswered for 57 minutes. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 Review, on 03/07/11, of the facility's records of self-reported events found Resident #78 had been fallen to the floor on 01/23/11, after being left unattended on a bedside commode. Included in the facility's internal was a call light log, which recorded the following response times by staff to Resident #78's call light once activated: - 02/05/11 at 7:39 p.m., the call bell was answered after 22.6 minutes - 02/05/11 at 8:03 p.m., the call bell was answered after 57.9 minutes - 02/19/11 at 7:06 p.m., the call bell was answered after 13.0 minutes. - 02/22/11 at 6:35 p.m., the call bell was answered after 15.9 minutes. - 02/23/11 at 7:15 p.m., the call bell was answered after 16.0 minutes. Interview with the director of nursing (DON - Employee #6), at 2:00 p.m. on 03/08/11, revealed the facility had a new nurse call system. According to the DON, the call system first rings into a pager worn by the nursing assistants on the resident's hall. If unanswered after 3 minutes, it rings into a system to notify nursing assistants on the next hall. If not answered after 3 minutes, it then rings into the pager carried by the unit charge nurse. This system continues to carry over to various members of staff if not answered in intervals of 3 minutes. On 03/09/11 at 12:00 p.m., the director of nursing (Employee #6) could offer no explanation why it would take 57.9 minutes to answer Resident #78's call bell on the evening of 02/05/11. She further stated the facility had contacted a repairman to verify the call system was working properly. A report subsequently provided by the DON revealed the repairman serviced the system on 03/03/11, and no problems were found affecting the 100 hall (the hall on which Resident #78 resided). .",2014-07-01
11293,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,280,D,1,0,MHV411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of the facility's fall prevention program, the facility failed to revise the care plan and update the nursing assistant worksheet for one (1) of ten (10) sampled residents when the resident returned from a hospital stay and was assessed as requiring additional staff assistance with activities of daily living (ADLs). Resident #78 was readmitted to the facility after a hospital stay following a [MEDICAL CONDITION]. Upon readmission to the facility, she was identified as having poor sitting balance and needing increased physical assistance from staff with transfers and toilet use. The facility also assessed Resident #78 as being at high risk for falls, for which there was no evidence of an updated care plan. On 01/23/11, Resident #78 was placed on the bedside commode and left unattended; she subsequently fell and suffered a concussion and abrasions to both knees. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 1. Record review revealed Resident #78 was an [AGE] year old female who was transferred to the hospital on [DATE] for [MEDICAL CONDITION], and she was readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Further record review revealed, on 01/23/11, Resident #78 was placed by staff on a bedside commode and left unattended. Staff later found her in the floor. She was sent to the hospital and diagnosed with [REDACTED]. - 2. According to an abbreviated quarterly MDS with an ARD of 12/06/10, in Section G0300 (balance during transitions and walking), the assessor encoded Resident #78's performance on Items A, D, and E (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer, respectively) as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 required the limited assistance of two (2) or more persons with transferring and toilet use. When assessing the resident's sitting balance using a form titled ""Tinetti Assessment Tool: Balance"" (completed on 01/06/11), the assessor scored Resident #78 as ""1"", indicating she ""(l)eans or slides in chair"". According to a significant change in status MDS with an ARD of 01/12/11, in Section G0300, the assessor again encoded Resident #78's performance on Items A, D, and E as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 now required the extensive physical assistance of two (2) or more persons with transferring and toilet use. On 01/14/11, the assessment coordinator (Employee #85) completed a falls risk assessment on Resident #78, resulting in a score of ""16"". (Note: A score above ""10"" indicates the resident is at risk for falls.) On her last fall risk assessment dated [DATE], she scored ""9"", indicating she was not at high risk for falls at that time. She had experienced a decline since her previous fall risk assessment. - 3. According to the facility's fall prevention program, once the falls risk assessment is complete, interventions should be set in place and the resident's should be care plan updated. Review of the resident's care plan revealed the following problem statement dated 06/16/09 - 04/19/11: ""Decrease in physical mobility due to left sided weakness, tremors, deconditioning."" The goal associated with this problem statement, dated 06/16/09 - 04/19/11, was: ""Will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin breakdown, fall related injury thru next 90 days."" Interventions to achieve this goal were: ""Observe, report to MD prn (as needed) s/sx (signs and symptoms) of immobility (contractures, forming of (sic) worsening, thrombus formation, skin breakdown, fall related injury. PT/OT referrals as indicated. Provide supportive care, assistance with mobility as needed. Document assistance needed. Keep items within easy reach of functional side (right), if one sided weakness is present. Administer medications and treatments as ordered and monitor for side effects."" Only after the resident's fall on 01/23/11 was a plan developed to specifically address falls. The following problem statement was added on 01/24/11: ""At risk for falls related to antidepressant, weakness, and past history of falls."" The goal associated with this problem was: ""Resident will not have any additional falls with injury thru the next 90 days."" The interventions to achieve this goal were: ""Ensure resident has on footwear with non-skid soles prior to getting up. Resident is two assist for transfers, up to C/V chair for mobility. Observe fatigue level: do not tire resident, report C/O (complaints of) weakness / intolerance, dizziness, pain or confusion. Allow for rest periods during the day. Resident is not to be left unassisted while toileting. Observe for side effects associated with medication use. PT treatment as ordered to improve functional status."" - 4. In an interview on 03/09/11 at 10:00 a.m., Employee #85 confirmed she had not updated Resident #78's care plan upon her readmission to the facility, to reflect her need for additional staff assistance with ADLs, especially her need for staff supervision during toilet use. The care plan was updated on 01/24/11, the day after the fall. .",2014-07-01
11294,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,323,G,1,0,MHV411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of the facility's fall prevention program, the facility failed to provide adequate supervision to prevent avoidable accidents for one (1) of ten (10) sampled residents. Review of her minimum data set (MDS) assessments, with assessment reference dates (ARDs) of 12/06/10 and 01/12/11, revealed Resident #78 was ""not steady, only able to stabilize with human assistance"" when moving from a seated to a standing position, moving on and off the toilet, and completing surface-to-surface transfers. Review of the resident's fall risk assessment dated [DATE] revealed a score of 9. Persons receiving a score of 10 or greater are considered at high risk for falling; Resident #78 was not considered to be at high risk for falls at that time. Resident #78 was hospitalized from [DATE] until 01/05/11. On 01/06/11, Resident #78 was assessed as having poor sitting balance. On 01/14/11, she scored 16 on the fall risk assessment, indicating she was now at high risk for falls. Safety measures were not implemented to promote fall prevention in accordance with the facility's fall prevention program, and neither Resident #78's care plan nor the nursing assistant worksheet was revised to address her high risk for falling. On 01/23/11, Resident #78 was placed on the bedside commode and left unattended. She was later found on the floor. She was sent to the hospital and diagnosed with [REDACTED]. Resident #78's care plan and nursing assistant worksheet were not revised, to address the need for staff to remain with her when using the toilet, until after she fell and sustained injuries requiring medical intervention. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 1. Record review revealed Resident #78 was an [AGE] year old female who was transferred to the hospital on [DATE] for cardiac arrest, and she was readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Further record review revealed, on 01/23/11, Resident #78 was placed by staff on a bedside commode and left unattended. Staff later found her in the floor. She was sent to the hospital and diagnosed with [REDACTED]. Review of the facility's internal investigation into the 01/23/11 fall revealed the following (quoted verbatim): ""... LSW (licensed social worker - Employee #62) spoke with various staff, from all 3 shifts, answered varied on whether or not resident should or could be left alone on toilet. For example, (name of Employee #100), LPN did not know that resident should be assisted by staff 'once on toilet, staff had left alone several times that night'. (Name of Employee #97) stated '(she) was aware had had to stay with resident. CNA's statements also varied between shifts. CNA worksheets had not been updated from time resident had been readmitted following prior hospital stay on 1/05/2011, as to change from w/c to c/v chair, or 2 assist during toileting. ..."" The internal investigation contained the following statement from a nursing assistant (Employee #119) related to the incident on 01/23/11 (quoted verbatim), ""... I was not told I could not leave her in her room alone nor do we receive report half the time. Our worksheets are wrong more than half the time too so there isn't much to go by ..."" - 2. According to an abbreviated quarterly MDS with an ARD of 12/06/10, in Section G0300 (balance during transitions and walking), the assessor encoded Resident #78's performance on Items A, D, and E (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer, respectively) as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 required the limited assistance of two (2) or more persons with transferring and toilet use. When assessing the resident's sitting balance using a form titled ""Tinetti Assessment Tool: Balance"" (completed on 01/06/11), the assessor scored Resident #78 as ""1"", indicating she ""(l)eans or slides in chair"". According to a significant change in status MDS with an ARD of 01/12/11, in Section G0300, the assessor again encoded Resident #78's performance on Items A, D, and E as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 now required the extensive physical assistance of two (2) or more persons with transferring and toilet use. On 01/14/11, the assessment coordinator (Employee #85) completed a falls risk assessment on Resident #78, resulting in a score of ""16"". (Note: A score above ""10"" indicates the resident is at risk for falls.) On her last fall risk assessment dated [DATE], she scored ""9"", indicating she was not at high risk for falls at that time. She had experienced a decline since her previous fall risk assessment. - 3. According to the facility's fall prevention program, once the falls risk assessment is complete, interventions should be set in place and the resident's should be care plan updated. Review of the resident's care plan revealed the following problem statement dated 06/16/09 - 04/19/11: ""Decrease in physical mobility due to left sided weakness, tremors, deconditioning."" The goal associated with this problem statement, dated 06/16/09 - 04/19/11, was: ""Will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin breakdown, fall related injury thru next 90 days."" Interventions to achieve this goal were: ""Observe, report to MD prn (as needed) s/sx (signs and symptoms) of immobility (contractures, forming of (sic) worsening, thrombus formation, skin breakdown, fall related injury. PT/OT referrals as indicated. Provide supportive care, assistance with mobility as needed. Document assistance needed. Keep items within easy reach of functional side (right), if one sided weakness is present. Administer medications and treatments as ordered and monitor for side effects."" Only after the resident's fall on 01/23/11 was a plan developed to specifically address falls. The following problem statement was added on 01/24/11: ""At risk for falls related to antidepressant, weakness, and past history of falls."" The goal associated with this problem was: ""Resident will not have any additional falls with injury thru the next 90 days."" The interventions to achieve this goal were: ""Ensure resident has on footwear with non-skid soles prior to getting up. Resident is two assist for transfers, up to C/V chair for mobility. Observe fatigue level: do not tire resident, report C/O (complaints of) weakness / intolerance, dizziness, pain or confusion. Allow for rest periods during the day. Resident is not to be left unassisted while toileting. Observe for side effects associated with medication use. PT treatment as ordered to improve functional status."" - 4. In an interview on 03/09/11 at 10:00 a.m., Employee #85 confirmed she had not updated Resident #78's care plan upon her readmission to the facility, to reflect her need for additional staff assistance with ADLs. The care plan was updated on 01/24/11, the day after the fall. Employee #85 also stated the nursing assistant worksheet (a tool used to inform nurse aides of resident-specific care needs) was not updated until 01/28/11.",2014-07-01
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
11299,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-03-25,314,G,1,0,4NN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, review of Pressure Ulcers in Adults: Prediction and Prevention, Clinical Practice Guideline Number 3, AHCPR Pub. No ,[DATE]: [DATE], and staff interview, the facility failed to ensure two (2) of five (5) residents with pressure sores received the necessary services to promote healing and prevent new sores from developing. Resident #16, who was known to clench her hands, did not receive any services to prevent the development of Stage II and Stage II wounds to her palms caused by her fingernails; additionally, Resident #16's nurse contaminated the resident's coccygeal wound during a dressing change, and a nursing assistant massaged a reddened area over a bony prominence - an action known to cause tissue damage. Resident #59's nurse did not follow the current physician's orders [REDACTED]. Resident identifiers: #16 and #59. Facility census: 87. Findings include: a) Resident #16 1. Review of Resident #16's medical record found a nursing note, dated [DATE] at 10:40 a.m., stating, ""Resident observed to have Stage III pressure area to palm of right hand caused by fingernail of third digit of right hand. Area cleansed /c (with) wound cleanser, dried and [MEDICATION NAME] powder applied. Hand roll placed in right hand. Left hand noted to have two 1 cm x 1 cm Stage I pressure areas to inside of fourth digit touching third digit. Also, 0.5 cm x 0.5 cm fluid filled Stage II pressure area noted to palm of left hand caused by fingernail of fourth digit ... Apply [MEDICATION NAME] power /c with hand rolls at all times ... Measurement of Stage III 1.5 cm x 2 cm x 0.5 cm ..."" Review of the [DATE] treatment administration record (TAR) found the resident was receiving restorative nursing services to include passive range of motion, three (3) sets of ten (10) repetitions, to bilateral upper and lower extremities including all joints of fingers; these restorative services were originally ordered on [DATE]. The TAR documented the order was discontinued on [DATE]. Review of the care plan, in effect for the time period including [DATE] through [DATE] (when the pressure ulcers were discovered), found no instruction for nursing assistants on the floor to continue the passive range of motion to the resident's fingers, after the restorative nursing services were discontinued, to help prevent pressure-related injury to the resident's hands. The director of nursing (DON - Employee #19) was unable to provide any evidence that passive range of motion to the resident's hands was provided by staff between [DATE] and [DATE] (when the pressure ulcers were discovered to the resident's hands). The medical record contained no instructions or physician orders [REDACTED]. A nursing note, dated [DATE] at 10:40 a.m., documented the presence of ""contractures to hands"". A nursing note, dated [DATE], stated, ""Res (resident's) hands tightly closed in fist position per usual."" A nursing note, dated [DATE], documented, ""Res hand contracted per usual."" Multiple interviews with the DON, on the morning and afternoon of [DATE], could elicit no interventions on the facility's part to prevent the pressure-related injury to the resident's hands after the restorative nursing services were discontinued on [DATE]. 2. Observations of the dressing change to the resident's Stage IV pressure ulcer on the coccyx were conducted at 1:20 p.m. on [DATE]. A licensed practical nurse (LPN - Employee #5) was observed to wash her hands and put on clean gloves. She then placed her right hand into her uniform pocket to retrieve scissors and placed them on the nightstand. She pulled up her pants on the front and on both sides using her gloved hands. She then walked across the room, picked up a roll of trash bags which were on the resident's dresser, obtained one (1) bag, opened it, and placed it at the foot of the resident's bed. Employee #5 then removed the dressing from the resident's coccyx, exposing the open wound. She squirted sterile saline into the wound and reached in with her contaminated gloved fingers to pick out pieces of packing. She repeated this procedure multiple times. Employee #5 contaminated the resident's wound with any bacteria or other infective agents which could have been present in her uniform pocket, the outside of her uniform, or on the trash bags laying on the resident's chest of drawers. 3. Random observations to assure staff was turning the resident were conducted beginning at 2:00 p.m. on [DATE]. Upon entering the resident's room, observation found the resident positioned on her right side with her left hip exposed. The nursing assistant (NA - Employee #98) was observed to be vigorously massaging a reddened area on the resident's left hip. When asked why she was massaging the reddened area, Employee #98 stated, ""I'm old school, and that's how we were trained to do it."" Review of Pressure Ulcers in Adults: Prediction and Prevention Clinical Practice Guideline Number 3, AHCPR Pub. No ,[DATE]: [DATE], found the following: ""4. Massage ""Avoid massage over bony prominences. (Strength of Evidence=B.) ""Rationale ""Massage over a bony prominence has been used for decades to stimulate circulation, contribute to a sense of patient comfort and well-being, and assist in prevention of pressure ulcers. However, the scientific evidence for using massage to stimulate blood and lymph flow and avert pressure ulcer formation is not well established, whereas there is preliminary evidence suggesting that it may lead to deep tissue trauma."" b) Resident #59 Review of the medical record, on [DATE], found a physician's orders [REDACTED]. Review of the [DATE] treatment administration record (TAR), on [DATE], found no documentation of a dressing having been applied on [DATE]. Employees #5 (LPN), #74 (NA), and #98 (NA) assisted with an observation of the resident's coccyx at 1:25 p.m. on [DATE]. This observation found no dressing present to the open wound on the resident's coccyx. Employee #5 stated the dressing must have fallen off and she would immediately apply another one. An interview with Employee #5, on [DATE] at 2:45 p.m., revealed she had not followed the current physician's orders [REDACTED]. She stated she utilized the [DATE] physician's orders [REDACTED].",2014-07-01
11300,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-03-25,224,D,1,0,4NN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on the medical record review, observation, and staff interview, the facility failed to assure a nursing assistant (NA) promptly notified the licensed nurse when the NA discovered the wound dressing to a pressure sore was missing for one (1) of five (5) sampled residents, so a new dressing could be applied in a timely manner. Resident identifier: #59. Facility census: 87. Findings include: a) Resident #59 Review of the medical record, on 03/25/10, found a physician's orders [REDACTED]. Review of the March 2010 treatment administration record (TAR), on 03/25/10, found no documentation of a dressing having been applied on 03/24/10. Employees #5 (a licensed practical nurse - LPN), #74 (a NA), and #98 (a NA) assisted with an observation of the resident's coccyx at 1:25 p.m. on 03/25/10. This observation found no dressing present to the open wound on the resident's coccyx. Employee #5 stated the dressing must have fallen off and she would immediately apply another one. In an interview on 03/25/10 at 2:00 p.m., the NA assigned to care for the resident (Employee #74) stated she had toileted the resident before lunch and no dressing had been present at that time. When asked if she had reported to her nurse that the dressing was not present on the resident's coccyx, she stated she should have reported it but did not do so. An interview with the director of nursing (DON - Employee #19), on 03/25/10 at 2:45 p.m., confirmed Employee #74 should have immediately reported the missing dressing to her nurse. This failure to immediately notify the nurse of the missing dressing resulted in a delay in treatment to the resident's wound. .",2014-07-01
11301,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-06-10,281,B,1,0,4NN912,". Based on observation, medical record review, and staff interview, the facility failed to assure physician's orders to change the humidifier bottles on the oxygen concentrators were followed for four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of ""05/27/10"" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10. An interview with a licensed practical nurse (LPN - Employee #4) verified the humidifier bottle on Resident #23's bottle was dated 05/27/10. No resident appeared to be in distress from this failure to follow physicians' orders. .",2014-07-01
11302,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-06-10,514,B,1,0,4NN912,". Based on observation, medical record review, and staff interview, the facility failed to assure the clinical record for each resident was accurately documented in accordance with accepted professional standards. This deficient practice affected four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of ""05/27/10"" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10 and contained nursing documentation that the bottles had been changed on that date. The director of nursing (DON), when informed of the above observations at 9: 45 a.m. on 06/10/10 at 9:45 a.m., agreed the records were not accurately documented.",2014-07-01
11303,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,386,D,1,0,CKVD11,"Based on review of reports of allegations / investigations submitted to the Office of Health Facility Licensure and Certification (OHFLAC), medical records, staff interview, and review of the facility's investigation, it was determined a resident's physician did not document his visit until several days after the visit occurred. Resident identifier: #93. Facility census: 89. Findings include: a) Resident #93 This resident's closed medical record was selected based on a report of an allegation filed with OHFLAC. The resident had sustained a fall on 03/13/09. The fall had resulted in injuries to the resident in the form of a black eye and bruising of her elbows. The family alleged the resident had not received medical attention until they insisted she be sent out for x-rays. Review of the facility's investigation found the physician stated he had been in the facility on 03/14/09, and he had indicated he examined the resident. According to the report, the physician had stated the resident had a black eye and bruising to both elbows. He did not feel she needed any additional treatment. However, the physician's progress note, regarding his examination of the resident on 03/14/09, was not written until 03/18/09. .",2014-07-01
11304,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-11-24,281,E,1,0,ONKD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of employee job descriptions, review of Long Term Care Resident Assessment Instrument User's Manual, and review of Criteria for Determining Scope of Practice for Licensed Nurses, revised July 17, 2009, the facility failed to assure that services provided by the facility met professional standards of quality. The facility employed a licensed practical nurse (LPN) to perform the duties reserved for the registered professional nurse (RN). The facility employed and delegated duties within the resident assessment instrument (RAI) process which were not within the LPN's scope of practice. The LPN was completing the summary of findings on the resident assessment protocol (RAP) which required the analysis of gathered assessment date related to resident conditions and potential outcomes, formulating care plan decisions, and establishing nursing [DIAGNOSES REDACTED]. Facility census: 89. Findings include: a) Review of resident medical records found the hand written summary of findings section of the RAPs completed for the east wing differed from the hand written sections of the summary of findings for the residents residing on the west wing of the facility. The review also found the summary of findings and care planning decision based on the summary were signed by an LPN (Employee #18) and cosigned by an RN (Employee #111). An interview was conducted with Employees #18 and #111 at 3:35 p.m. on 11/24/09. Both employees agreed the LPN completed the minimum data set (MDS), RAP, RAP summaries, care planning decisions, and formulation of care plans for the residents residing on the east wing, and the RN performed these duties for residents residing on the west wing. The director of nursing (DON) was asked the provide the job descriptions for Employees #18 and #111. Review of the job description provided on 11/24/09 at 4:15 p.m. for LPN Employee #18, signed 01/28/08, under the section entitled ""DEFINITION"" found the following: ""Works under the supervision of the Director of Nursing. Assures that the total needs of residents are met through the development of Minimal (sic) Data Assessments and Care Plan Coordinating."" Review of the Long Term Care Resident Assessment Instrument User's Manual found the RAPs are utilized to analyze assessment findings recorded on the MDS and consist of in-depth assessments of a resident's particular clinical conditions; the RAPs result in a determination of whether to address the condition in the resident's care plan. This analysis of data and further in-depth assessment, as well as the decision making process utilized to develop nursing [DIAGNOSES REDACTED]. Review of Criteria for Determining Scope of Practice for Licensed Nurses, revised June 17, 2009, found that activities that should not be delegated to the LPN include: ""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 judgement in determining the next step to take..."". Further review found Section II, entitled ""REVIEW EXISTING LAWS, POLICIES, AND STANDARDS OF NURSING PRACTICE"" contained the following language: ""Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care. The Boards receive many questions about the LPN's role in the assessment component of the nursing process. While the law does not specifically address the issue of the LPN's role in the assessment process, the rule clearly places the responsibility for the analysis of the data on the RN. It is the responsibility of the LPN to contribute to that data analysis by collecting objective and subjective data at the direction of the RN and by reporting and documenting the information collected. (From the OBON SOP brochure 2005)."" It was further noted that only the RN may establish nursing diagnoses, identify expected outcomes individualized to the client (resident), identify priorities in the plan of care, prescribe nursing interventions, and initiate nursing interventions. The LPN is restricted to participating and contributing to these processes. By analyzing assessment data, establishing nursing diagnoses, identifying priorities in the plan of care, prescribing nursing interventions and developing the plan of care for residents, this LPN was providing care and services not within her scope of practice.",2014-07-01
11305,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2011-02-11,223,G,1,0,3UQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's self-reported allegations of resident abuse / neglect and staff interview, the facility failed to ensure one (1) of three (3) residents were free from abuse. One (1) resident suffered mental anguish after staff members intentionally deprived him of free access to his bed. The facility staff did not allow this resident (who was physically able to get into his bed on his own) to access his bed freely. Staff kept the bed elevated with side rails up so as to prevent him from accessing his bed without staff assistance, and then failed to assist him to bed for a period of approximately five (5) during which time he begged staff members to put him in his bed. Resident identifier: #8. Facility census: 43. Findings include: a) Resident #8 1. On 02/11/11 at approximately 11:00 a.m., review of the facility's self-reported allegations of resident abuse / neglect revealed a report dated 01/05/11, which was submitted to the Office of Health Facility Licensure and Certification (OHFLAC) Nurse Aide Registry. The report identified Employee #33 (a nurse aide) as the alleged perpetrator and Resident #8 as the alleged victim. The allegation was: ""(Employee #33) states she elevated the resident's bed so that he would not get into the bed. She states this was done in an attempt to prevent the resident from choking on tobacco, as he refuses to remove the tobacco from his mouth prior to getting in bed. This information was obtained during a counseling session with (Employee #33) on 01/04/11."" -- 2. The five (5) day follow-up report dated 01/12/11 (an extension was granted by OHFLAC due to an employee being on sick leave) stated: ""(Employee #33) states she elevated the resident's bed so he could not get into bed by himself. Done to prevent resident from getting into bed with tobacco in his mouth and possibly choking (sic). DON (director of nursing - Employee #141) stated it was okay to raise the bed for safety purposes. However, there was no order to raise the bed and this was not a part of the resident's care plan."" The facility substantiated the allegation against Employees #33 and #141; however, the facility identified the issue as neglect as opposed to abuse. -- 3. The facility's internal investigation into this incident (titled ""Long Term Care Investigation"") was completed by the facility ' s administrator (Employee #139). The allegation was stated as follows: ""Resident (name of Resident #8)'s bed was elevated so that he could not get into bed by himself. This was allegedly done so that the resident would not get into bed with tobacco in his mouth, putting him at risk for choking and/or aspiration."" The investigative report included summaries of interviews conducted by the administrator with various staff members by the administrator on 01/06/11, 01/10/11, and 01/11/11, including the following: - Employee #68 (housekeeping), interviewed on 01/06/11 - ""(Employee #68) states that one evening while he was working the resident asked for a 'chew.' He states it was probably around five or six o'clock. (Employee #68) states the resident spit the tobacco out and said he would like to go to bed. He states this went on for approximately four hours. ""(Employee #68) states he went in at 21:30 (9:30 p.m.) to pull the trash and the resident was still asking to go to bed. He states that at 22:30 (10:30 p.m.), 'the (sic) man still wanted to go to bed.' (Employee #68) states the resident begged to go to bed. He states the resident's bed was 'in the air' the whole time. (Employee #68) states the resident asked him to put his bed down, but (Employee#68) told the resident he could not put the bed down. (Employee #68) states he reported the incident to (Employee #99), CNO (chief nursing officer)."" - Employee #10 (licensed practical nurse - LPN), interviewed on 01/10/11 - ""(Employee #10) states she was doing a medication pass on December 14, 2010 at approximately 17:30 (5:30 p.m.). She states she was returning to the medication room when (Resident #8) asked her for 'a chew and a pop.' (Employee #10) states that at 19:30 (7:30 p.m.) the resident was at the gate at the nurse's station saying, 'Honey, put me in the bed. My bed is raised up.' (Employee #10) states she informed the resident that 'they' didn't want him to get in bed with a chew. (Employee #10) states (Resident #8) gave her his tobacco. She states she told the resident's nurse, (Employee #30) (LPN) that he wanted to go to bed. ""(Employee #10) states she personally did not see the resident's bed up because she was 'not allowed' to go on that side of the unit. She states (Employee #68) told her it was true, that the resident's bed was up. (Employee #10) states she told the resident to follow (Employee #33 - a nurse aide) and that she would put him to bed. ""(Employee #10) states that at 21:50 (9:50 p.m.) the resident was following her during a medication pass and said he wanted to go to bed. (Employee #10) states that she told (Employee #30 - an LPN), 'If someone doesn't put him in bed, I'm giving him another chew.' (Employee #10) states that (Employee #140 - a registered nurse) came on the unit and she asked (Employee #140) to look and see if the resident's bed was up. (Employee #10) states that (Employee #140) told her the bed was up. (Employee #10) told (Employee #140) not to say anything. ""(Employee #10) states she called (Employee #141), DON, the next morning. (Employee #10) states (Employee #141) asked her, 'What are you doing on that side?' (Employee #10) states she told (Employee #141) that somebody was putting the resident's bed up. She states (Employee #141) replied, 'Day shift does it.' (Employee #10) states she told (Employee #141) that (Employee #68) told her the resident's bed was up. (Employee #10) states that (Employee #141) replied, '(Employee #68) comes behind the desk, too, and he's not supposed to.' (Employee #10) further states that (Employee #39), LPN, told her that (Employee #141) had asked her to write an order to put the bed up, but (Employee #39) said she was not comfortable doing this. ..."" - Employee #17 (a nurse aide), interviewed on 01/06/11 - ""(Employee #17) states that (Employee #33) told her she needed to lock the resident's bed and that (Employee #141) had told her she could put the bed up and lock it. (Employee #17) states that the bed has been put up several times by (Employee #33) and that this has been going on for about a month to a month and a half."" - Employee #142 (physician), interviewed on 01/06/11 - ""(Employee #139) asked (Employee #142) if he had given (Employee #39), LPN, a verbal order to elevate the bed. (Employee #142) states that is not exactly the way it happened. He states that (Employee #141) discussed with him the resident's fall risk, stating that if the resident gets into bed by himself the bed alarm will not be turned on. (Employee #142) states he told (Employee #141) that if it was within the law to raise the bed it was fine. He states he didn't know if that would be like a restraint and also that he did not know if that would keep the resident from falling. He states he does not think that he gave an order for [REDACTED]. -- 4. Included with the facility's investigative report was a typed statement from Employee #141 dated 01/11/11, explaining her why she allowed staff to raise Resident #8's bed up to a point where he could not access it independently. A portion of the letter stated (quoted verbatim), ""... in (Resident #8)'s care plan he is to have at least a one person assist to enter and exit his bed, as he is unable to bear weight on his feet, in his care plan he is to have a bed alarm on at all times, to assure that he does not attempt to exit bed unassisted. (Resident #8) chews tobacco, (Employee #33) C.N.A. came to me expressing her concern that she was unable to comply with (Resident #8's) care plan, nor protect him from aspiration, due to his non compliance. She stated that he would ask the nurses for chewing tobacco, wheel himself back to his room, at which time he would stand on one foot and throw himself into the bed without assistance, the staff unaware of him getting back in bed, his bed alarm would not be on, he would lie in bed with his mouth full of tobacco, falling asleep, the staff would find him asleep, tobacco amber running out of his mouth, his pillow case and bedding covered with tobacco stains, which would be enough fluid that could cause aspiration if the right circumstance presented itself. She told me that she had been raising his bed to the highest level and raising all side rails, so that (Resident #8) would have to ask for assistance to get into bed, which the care plan states that he is to be assisted, at this time she could not assure that he was not going to bed with tobacco in his mouth, this would prevent the chance of aspirating on tobacco, and the bed alarm could be set, to comply with the residents plan of care. At no time was any of the residents' rights denied him, he was never placed in any danger, because with the bed in the highest position and all rails up he could not attempt to enter the bed without assistance. ..."" -- 5. An interview with the administrator and review of the documentation from the facility's internal investigation revealed Resident #8 had the physical ability to get into bed, even though the facility did not want him to do so without staff assistance for safety purposes. Staff had placed a bed alarm on the resident's bed to alert them when he got out of bed, because he was at risk for falls. The investigation by the facility concluded that Employee #141 had given Employee #33 permission to raise the resident's bed up in the air to prevent him from getting into his bed at will. The investigation also showed the resident had gone to his room and saw his bed raised to the point he could not get into it by himself. He had begged Employee #68 to place him in the bed, because he could not do so himself. On 12/14/10, from approximately 5:30 p.m. until at least 10:30 p.m., Resident #8 asked various staff members to put him to bed, because he could not access his bed independently. Staff deprived Resident #8 of the ability to get into his bed on his own. This action caused him to wait several hours, as well as to beg staff members for assistance, before he was assisted into his bed. .",2014-07-01
11306,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2011-02-11,225,D,1,0,3UQL11,". Based on a review of the facility's self-reported alleged violations of resident abuse / neglect and staff interview, the facility failed to ensure all allegations of abuse / neglect made against employees were reported to the appropriate State officials as required by law. Facility documentation revealed Employee #33 (a nurse aide) elevated Resident #8's bed to prevent him from accessing his bed at will. The facility reported Employee #33 to State officials as required; however, the facility's internal investigation revealed Employee #141 ( a registered nurse) was also involved in the incident, and there was no evidence that this employee was reported as required. Resident identifier: #8. Facility census: 43. Findings include: a) Resident #8 On 01/05/11, the facility self-reported Employee #33 to the State nurse aide registry. The allegation stated, ""(Employee #33) states she elevated the resident's bed so that he could not get into the bed. She states this was done in an attempt to prevent the resident from choking on tobacco, as he refuses to remove the tobacco from his mouth prior to getting in bed."" This information was obtained during a counseling session with Employee #33 on 01/04/11. The facility identified the incident as having occurred on or about 11/26/10. The facility's five (5) day follow-up report stated, ""Neglect substantiated on the part of (Employee #33) (nurse aide) and (Employee #141) RN/LTC (long term care director) director of nurses."" However a review of the information submitted to State officials revealed Employee #141 had not been identified as an alleged perpetrator and, consequently, had not been reported to any State agency as required.",2014-07-01
11307,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-04-10,323,D,0,1,4JJY11,"Based on observations, medical record review, and staff interviews, the facility failed to ensure the residents' environment was as free of accident hazards as possible. One (1) of the three (3) styles of beds in use in the facility exhibited gaps between the side rail and the mattress sufficient to pose a risk of entrapment to a resident's arm or leg. Six (6) of nine (9) residents on the sample were affected. Additionally, a housekeeper was observed mopping the floor in the hall. She mopped across the entire hall and did not leave a dry lane for residents who were traveling through the hall. One (1) resident was observed removing the bar from a Merrywalker-type chair so she could sit on her bed. She had difficulty lifting her foot over the strap of the chair, which passed between her legs, in order to exit the chair. This created a falls hazard. Resident identifiers: #5, #9, #22, #34, #35, #47, and #12, and any residents ambulating through the hall. Facility census: 47. Findings include: a) Residents #5, #9, #22, #34, #35, and #47 These residents had been observed periodically throughout the survey to have their side rails elevated when they were in bed. On the morning of 04/10/09, nine (9) of the twelve (12) residents on the sample were still in bed. The space between the side rails and the mattresses were evaluated. It was found that one could easily pass one's arm (to a height above the elbow) through the space between the mattress and below the the end of the side rails on these residents' beds. The thin arms and legs of the residents could easily become entrapped between the rails and the mattress. Resident #47's bed rails were covered with fitted pads, but the pads did not prevent passage of one's arm between the rails and the mattress. Three (3) styles of beds and side rails were assessed. Two (2) styles did not pose a problem. However, the third type of bed had side rails that were offset from the frame, resulting in a gap between the side rail and mattress. b) Housekeeping On 04/09/09 at 10:40 a.m., a housekeeper was observed mopping the hallway. She would mop a section of the hall from one (1) side to the other, then move to the next part of the hall and again mop clear across the hall. This resulted in residents and staff having to walk on wet, or partially wet, tiles increasing the potential for falls. c) Resident #12 On the morning of 04/10/09, while assessing this resident's ability to release herself from a Merrywalker-type chair, the resident was observed to enter her room and remove the bar from the front of the chair. She was wanting to sit on her bed. She tried to stand and lift her right foot over the strap that went from the front of the device, between her legs, and to the seat of the chair. She was unable to lift her foot high enough to clear the strap. She then sat on the seat of the chair and began to try to lift her foot over the strap. After several attempts, she was able to clear the strap, get out of the chair, and sit on the side of her bed. The director of nursing was present during this observation. The possibility of the resident becoming entangled in the strap was discussed. She later related the strap had been removed from the chair. .",2014-07-01
11308,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,225,E,1,0,HMYP11,"Based on record review and staff interview, the facility failed to immediately report and thoroughly investigate an allegation of neglect by Employee #33, a nursing assistant (NA), involving Resident #3, and failed to investigate the reasons six (6) additional current residents and five (5) discharged residents refused to be cared for by Employee #33. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a NA (Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair, with the resident's feet dragging under the shower chair twice. The RT stated the NA continued pushing the resident, even though the resident yelled, ""My foot, my foot! You're hurting my foot!"" The NA did not stop pushing the shower chair until the RT intervened. Additionally, the RT reported to the facility that Employee #33 ""threw"" briefs onto each resident's bed and that Employee #33 ""had a bad attitude."" After the RT reported the incident to the facility, but the facility did not report it to State agencies as neglect, nor did the facility thoroughly investigate the incident. The resident's roommate, whom the facility identified as ""interviewable"", was present, yet the facility did not interview this resident regarding the incident. In addition, there was no statement (written or dictated) from the alleged perpetrator (Employee #33). Facility staff interviewed another NA (Employee #36), who witnessed the briefs thrown on the beds and confirmed that Employee #33 ""did throw the briefs onto each of the beds and that she (Employee #33) did have a bad attitude."" According to the facility's grievance form, the social worker (SW) and director of nursing (DON) interviewed Employee #33, who denied the incident, said the resident's foot was caught only once, and that she ""laid the diapers on the bed."" Review of the grievance form, completed by the SW, revealed no evidence that the incident was ever considered an incident of neglect and/or abuse. b) Residents #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53 During the survey, it was discovered these residents refused to allow Employee #33 to provide care for them. None of these refusals were addressed as allegations of abuse or neglect. The facility had compiled the names of these residents on a list and were working the schedule so that they were not assigned to Employee #33. The facility had not ascertained and/or investigated the reasons these residents did not want Employee #33 to care for them. These processes were necessary to rule out abuse and/or neglect. .",2014-07-01
11309,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,226,E,1,0,HMYP11,"Based on record review, staff interview, and policy review, the facility failed to operationalize their policies and procedures regarding identification, investigation, and reporting of suspected neglect or abuse. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a nursing assistant (NA - Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair and dragging this resident's foot under a shower chair twice. According to the director of nursing (DON) at 12:00 p.m. on 07/03/04, the RT did not report the incident to anyone. The DON stated, ""We heard rumors and sought her out."" Review of the facility's abuse / neglect policy revealed, ""All personnel must promptly report any incident or suspected incident of resident neglect, abuse..."" This information is in the section of the policy entitled ""Reporting"". The RT was a hospital employee, not an employee of the nursing home; however, all personnel who work with residents in the nursing facility are required to know and operationalize facility abuse policies. In addition, the facility failed to operationalize its procedures to notify the appropriate State regulatory agencies, and failed to operationalize its procedures to investigate an allegation of neglect regarding this incident. b) Residents #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53 During the survey, it was discovered these residents refused to allow Employee #33 to provide care for them. The facility had not investigated the reasons why these residents were refusing care from Employee #33. At 12:15 p.m. on 07/03/09, the social worker (SW) was asked how the facility became aware that these residents did not want Employee #33 to provide their care. The SW stated the nurses informed them. When asked if the residents had been asked why they were refusing care by Employee #33, the SW stated they had not. The facility failed to operationalize procedures to rule out possible abuse or neglect. It was also confirmed, at that time, that none of the situations had been immediately reported or thoroughly investigated as required by law. The facility had not operationalized its procedure which stated, ""When a resident or other person makes an allegation (or complaint) to an employee, the employee is responsible for promptly assisting the resident in bringing the matter to the attention of the Long-term Care Coordinator, the Charge Nurse, or the Social Worker, by immediately completing a Resident Complaint Form..."" This form was not completed for any of these residents. Since there were reasons why the residents refused care by Employee #33, the facility had an obligation to ascertain why. This was necessary to rule out possible abuse and/or neglect. c) Since twelve (12) incidents of possible neglect or abuse were not reported or investigated, it was determined the facility had not operationalized the training necessary to assure all employees were aware of what constitutes neglect and/or abuse and how staff should report allegations of neglect and/or abuse. Additionally, the facility also failed to operationalize their procedures for reporting and investigating suspected incidents of abuse. .",2014-07-01
11310,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,323,D,1,0,HMYP11,"Based on observation and staff interview, the facility failed to identify and mitigate an accident hazard for one (1) of seven (7) sampled residents. Resident identifier: #36. Facility census: 47. Findings include: a) Resident #36 On 07/01/09 at 10:10 a.m., this resident was observed attempting to get out of bed. According to nursing staff present at that time, the resident was able to get out of bed unassisted and did so at will. The resident had full length gap guards on her bed. They ran from the top of the bed to the bottom of the bed. The resident was observed extending her legs over the guard at the foot of her bed, to get out of the bed. Due to the guard, the resident was unable to simply position herself on the side of the bed, allow her feet to touch the floor, then rise normally. Additionally, since the guards were not permanently attached to the bed, if one (1) of the guards happened to slide away from the side of the bed the resident was exiting, the resident could become entangled, causing a fall. .",2014-07-01
11311,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-08-25,246,E,1,0,I0YS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to ensure the individual preferences were accommodated for one (1) of five (5) sampled residents. Resident #43 was aggressive and combative with staff during morning care when given baths / shower. Review of the most recent minimum data set assessment (MDS) found the resident preferred to be bathed / showered in the evening. Interview with the facility's director of nursing (DON) revealed there was no schedule to identify which residents were to receive baths / showers in the mornings versus evenings. The DON indicated residents received showers whenever they were needed. There was no evidence to indicate individual bathing preferences of this (or any other resident) was being accommodated. This practice had the potential to affect any residents who had expressed a preference to be bathed / showered at a particular time of day. Resident identifier: #43. Facility census: 73. Findings include: a) Resident #43 During an interview on 08/24/10 at 11:30 a.m., the family of Resident #43 reported this resident was not a ""morning person"" and that he had a history of [REDACTED]. The family member also noted the resident had been receiving showers / baths in the morning and was becoming aggressive with staff, receiving injuries as a result. Review of the resident's annual comprehensive MDS, with an assessment reference date of 05/05/10, revealed in Section AC (Customary routines) that the resident preferred bathing in the evening. On 08/25/10 at 12:00 p.m., the DON was asked for a resident shower schedule that would indicate this resident was receiving showers in the evenings. The DON reported the facility did not have any schedules to indicate on what day or at what time each resident received a shower or bath. In a subsequent interview on 08/25/10 at 1:45 p.m., the DON was unable to provide any further information on how any individual resident's bathing preferences were communicated to direct care staff or whether Resident #43's preference to be showered in the evenings was being accommodated. .",2014-07-01
11312,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-08-25,279,D,1,0,I0YS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, it was determined the facility failed, for one (1) of five (5) sampled residents, to develop a comprehensive care plan that described bathing / shower services to be provided in a manner that accommodated his personal preference to be bathed in the evenings as noted. Resident identifier: #43. Facility census: 73. Findings include: a) Resident #43 During an interview on 08/24/10 at 11:30 a.m., the family of Resident #43 reported this resident was not a ""morning person"" and that he had a history of [REDACTED]. The family member also noted the resident had been receiving showers / baths in the morning and was becoming aggressive with staff, receiving injuries as a result. Review of the resident's annual comprehensive MDS, with an assessment reference date of 05/05/10, revealed in Section AC (Customary routines) that the resident preferred bathing in the evening. On 08/25/10 at 12:00 p.m., the DON was asked for a resident shower schedule that would indicate this resident was receiving showers in the evenings. The DON reported the facility did not have any schedules to indicate on what day or at what time each resident received a shower or bath. In a subsequent interview on 08/25/10 at 1:45 p.m., the DON confirmed there was no care plan developed to ensure this resident's preference of baths / showers in the evenings was communicated to direct care staff.",2014-07-01
11313,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-04-21,280,D,1,0,J0DV11,". Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of eight (8) sampled residents, to address exit-seeking behaviors when Resident #52 attempted to elope from the facility. Facility census: 73. Findings include: a) Resident #52 Record review revealed Resident #52 had attempted to exit the facility on two (2) occasions. The medical record stated that, at 11:00 p.m. on 03/16/10, the resident attempted to follow staff out of the South door and was redirected easily. The medical record documented that, again at 12:00 a.m. on 03/17/10, the resident attempted to exit the South back hall and was redirected easily. Interview with the social worker, on 04/21/10 at 1:15 p.m., revealed she had no knowledge of the resident's elopement attempts. The social worker stated an elopement assessment is completed with regular minimum data set assessment schedule, and it was not updated due to the fact that she had no knowledge this behavior had occurred. The social worker also agreed the resident's care plan had not been updated to refect this exit-seeking behavior. .",2014-07-01
11314,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-04-21,319,D,1,0,J0DV11,"**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 one (1) of eight (8) sampled residents received appropriate treatment and services for verbally and physically aggressive behaviors. Resident identifier: #52. Facility census: 73. Findings include: a) Resident #52 Record review revealed Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was noted to lack capacity to understand and make his own health care decisions, and his medical power of attorney representative (MPOA) - who was his spouse - was his surrogate decision-maker. His medication orders included [MEDICATION NAME] via intramuscular injection (IM) ""as needed"" (PRN) for agitation and [MEDICATION NAME] by mouth PRN for agitation, hitting, kicking, and threatening others. Documentation in Resident #52's medical record noted he was physically aggressive and verbally abusive toward staff members, for which PRN psychoactive medication was administered. On six (6) different occasions during the month of March 2010, the resident displayed physically aggressive and verbally abusive behaviors towards staff. PRN medication interventions were administered on five (5) of the six (6) instances. On four (4) occasions, he received [MEDICATION NAME], and on one (1) occasion, he received [MEDICATION NAME] IM. The resident was also noted to have had at least two (2) episodes month-to-date in April 2010 for which he received [MEDICATION NAME] for verbally abusive and/or physically aggressive behaviors. Resident #52 was not currently being treated with routinely scheduled psychoactive medication(s). There was no indication in the medical record to reflect the facility had addressed with the resident's MPOA the option of obtaining a psychiatric consult. However, by exit on 04/21/10 4:30 p.m., the co-director of nursing (Employee #19) reported the resident had a psychiatric appointment scheduled, but she was unsure of the date. In an interview with the social worker at 1:15 p.m. on 04/21/10, she stated the resident's behaviors were, for the majority of the time, mild and that he was easily redirected with food. At this time, the social worker was alerted to an entry in the resident's medical record at 8:35 p.m. on 03/25/10, recording that the resident had actually hit a licensed practical nurse in the stomach and grabbed her by the wrists, stating ""I'm going to hurt you."" In an interview with the resident's MPOA at 6:50 p.m. on 04/21/10, she stated she was very concerned about the resident's behaviors. The MPOA stated he can become angry but he does not mean to be. She reported the resident can frequently go five (5) to six (6) days without any sleep. The MPOA stated she has asked the staff to give him a mild sedative, but she noted it did not appear that anyone listens to her requests. The MPOA also stated that, if the resident's behaviors were more manageable, she would like to take the resident home, as his physical condition has improved greatly since admission. The MPOA was very pleased that an appointment with a psychiatrist was being scheduled for her husband. .",2014-07-01
11315,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-04-21,441,D,1,0,J0DV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure a safe, sanitary environment to prevent the development and transmission of disease, as evidenced by a nurse who did not change gloves and wash hands during dressing changes as per facility policy and procedure. This was evident for two (2) of eight (8) sampled residents. Resident identifiers #5 and #46. Facility census 73. Findings include: a) Resident #5 Observation, at 10:35 a.m. on 04/20/10, found a licensed practical nurse (LPN - Employee #5) doing a dressing change on Resident #5's right foot. Employee #5, after washing her hands and donning gloves, removed the dressing from Resident #5's foot. The LPN did not change her gloves or wash her hands after removing the contaminated dressing and prior to cleansing the affected area. b) Resident #46 Observation of dressing changes to the lower legs for Resident #46, on 04/20/10 at approximately 1:45 p.m., revealed the nurse (Employee #5) washed her hands and donned gloves prior to beginning the procedure. She then cut the Kling gauze wrap with scissors, removed the gauze and two (2) [MEDICATION NAME] dressings from the right lower leg, cleansed the open area on the right lower leg with 4 x 4 gauze sponges saturated with normal saline, patted the area dry to the right lower leg with a 4 x 4 gauze and then proceeded to change the dressing on the resident's left lower extremity. Employee #5 cut the Kling wrap with scissors and removed it and two (2) [MEDICATION NAME] dressings from open wounds to the left lower extremity, removed her gloves, washed her hands, and then donned a new pair of gloves prior to cleansing and drying the wounds on the left lower leg. c) A request was made of the director of nursing (DON - Employee #24) for the facility's treatment policy at 11:00 a.m. on 04/20/10. Employee #24 provided a policy and procedure for performing treatments on residents with open areas at 11:30 a.m. on 04/20/10. The policy stated, under Item #4, ""When cleansing Decubitus and there is more than one area, there must be only one area cleansed at a time and then the nurse must also dispose of her gloves, wash hands and re-glove before starting to finish the rest of the procedure."" In an interview at 2:00 p.m. on 04/20/10, the DON was informed that Employee #5 removed the soiled dressing from Resident #5's foot and cleansed the site without first removing gloves and washing her hands, which resulted in possible contamination. The DON was also informed of Employee #5's failure to remove her gloves and wash her hands after removing the soiled dressing from Resident #46's right lower extremity prior to cleansing the affected areas. During this interview, the DON agreed the nurse should have removed her gloves and washed her hands after removing the soiled dressings and prior to cleansing the wounds. .",2014-07-01
11316,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2010-04-21,463,D,1,0,J0DV11,". Based on observation, staff interview, resident interview, and record review, the facility failed to provide for an adequate nurse call system whereby staff was enabled to respond to requests for assistance in a timely manner. Observation of eight (8) sampled residents revealed one (1) resident was housed in a room designated on the facility's floor plan as a ""treatment room""; there was no nurse call system in place by the bed, although there was a working call bell in the corner of the room by the toilet; the resident was provided a hand-held bell with a clapper. This resident was care planned to include an intervention for staff to respond to requests timely. Resident identifier: #46. Facility census: 73. Findings include: a) Resident #46 Observations during the initial tour, on 04/19/10 at 1:20 p.m., revealed Resident #46 had an assigned room on the North Hall with his name outside the door. Treatment observation, on 04/20/10 at approximately 1:45 p.m., revealed he was actually residing in the treatment room, which had no enclosed toilet; rather, the commode was situated in a corner of the room behind a screen. There was an emergency call bell in the corner by the toilet. The resident's bed was in the opposite corner, and he had a hand-held bell with a clapper with which to call for staff assistance in place of having a nurse call light. The licensed practical nurse (LPN - Employee #5), when asked, said this room was used at times for residents with infections, but Resident #46 was not infectious. Inspection of the floor plan posted on a wall on the North Wing revealed the room in which Resident #46 currently resided had a room number, but it was also labeled as a treatment room. There were thirteen (13) numbered rooms on each of the two (2) halls, with two (2) of the thirteen (13) designated as treatment rooms. During an interview on 04/21/10 at 7:00 a.m., Resident #46 said he liked this room and wanted to stay in it; he couldn't get along with the ""old man"" in the other room and asked to move to another room. When asked about not having an enclosed toilet, he stated he had a blind in the window and a screen in front of the toilet and felt as though he had all the privacy he needed. He specified he did not want to move out of the current room. On 04/21/10 at 2:05 p.m., Resident #46's hand-held bell with a clapper was rung when no staff members were at the nurse's desk. Three (3) nursing assistants (Employees #93, #33, and #84) and a nurse (Employee #28) came to or walked by the nurse's desk within the next ten (10) minutes, but none of them responded to the bell. Review of Resident #46's care plan revealed problem areas with mood, behavior, and psychosocial well-being, and approaches to deal with each of those areas included: ""Respond to requests timely."" Review of nurse's notes, dated 04/11/10, revealed he was moved at 7:00 p.m., although there was nothing specifically stating this was done at his request; the physician and director of nursing were notified promptly. During an interview with the licensed social worker (LSW) on 04/21/10 at 10:25 a.m., she stated there currently was no appropriate match in available rooms for Resident #46 or ways to move other residents at this point in time to accommodate moving him into a regular resident room, but they were working on it. Review of the current care plan revealed an approach to seek a therapeutic match for a roommate and to seek resolution to acute problems. The LSW stated Resident #46 was currently perceived as a threat to others, had been deemed to have capacity, and refused to go for a psychiatric consult which was scheduled for 04/19/10. During an interview with Resident #46 on 04/21/10 at 11:00 a.m., he stated he had an appointment to see a psychiatrist recently but he would not go. On 04/21/10 at approximately 3:30 p.m., the administrator said the facility was licensed for eighty-four (84) beds and they were working on getting another room for Resident #46, and they did not think he would be in there this long. After speaking with maintenance, she stated they will get the room wired to include a call light next to his bed. .",2014-07-01
11317,LAKIN HOSPITAL - STATE,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2011-01-12,323,G,1,0,630F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision to prevent an avoidable accident to one (1) of four (4) residents reviewed for swallowing problems. During the evening meal on 12/02/10, dietary staff provided for Resident #83 a mechanically altered meal contrary to his physician order [REDACTED]. Prior to the on-site investigation into this choking incident by the State survey and certification agency, the facility took prompt actions to identify and correct system failures that permitted dietary staff to send the wrong tray to a resident and that allowed the nursing staff to serve the wrong diet, to ensure this type of avoidable accident did not recur. Resident identifier: #83. Facility census: 90. Findings include: a) Resident #83 Review of facility records revealed Resident #83 suffered a choking episode during the evening meal on 12/02/10, which resulted in the need for nursing staff to administer the Heimlich maneuver to expel a bolus of food that obstructed the resident's airway. This choking episode was an avoidable accident, which resulted from the resident receiving and consuming foods that were not pureed in accordance with his physician-ordered therapeutic diet. Interview with the administrator and director of nursing (DON), on 01/10/11 at 3:20 p.m., revealed Resident #83 had resided on the B wing until 12/02/10, when a decline in his condition promoted the facility to transfer him to C wing where his health status could be more closely monitored. When, during the evening meal on 12/02/10, Resident #83's meal tray did not arrive on the new unit (C wing), nursing staff contacted the dietary department to request another tray. Two (2) residents on C wing (Residents #83 and #100) had the same last name. Dietary staff was not aware of Resident #83's room transfer and prepared a tray for Resident #100 (the other resident on C wing with the same last name). Resident #100 had a physician's orders [REDACTED].#83 had a physician's orders [REDACTED]. Nursing staff then proceeded to serve Resident #83 the mechanical soft diet, which resulted in the choking episode. Nursing staff immediately reacted to the choking by performing the Heimlich maneuver, which successfully dislodged the bolus of food that was obstructing Resident #83's airway. Nursing staff immediately notified the physician of the choking episode and received instructions to monitor the resident. On the following day, the resident sustained [REDACTED]. The administrative staff immediately began an investigation into the root cause of this adverse event. A comprehensive investigation by the facility's administrative staff identified that both dietary and nursing staff was responsible for this avoidable accident. The incident was reported to all State agencies as required. The staff members involved received suspensions, all dietary staff was re-educated on the need to carefully prepare meal trays in accordance with each resident's physician-ordered diet, and all nursing staff was re-educated on the need to verify that mechanically altered diets were correct prior to service to each resident, by reviewing each resident's tray card. The system failures that contributed to this adverse event were identified and corrected by the facility prior to this on-site complaint investigation by the State survey and certification agency.",2014-07-01
11318,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-03-30,282,D,1,0,RNQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide services to residents in accordance with their written plan of care and/or physician's orders [REDACTED]. This was found for three (3) of nine (9) sampled residents reviewed. Resident identifiers: #58, #60, and #56. Facility census: 94. Findings include: a) Resident #58 The medical record of Resident #58, when reviewed on 03/29/11 at 4:45 p.m., contained a ""Plan of Care"" card stating, ""BLOOD PRESSURE IN LEFT ARM ONLY PER PT. REQUEST."" The current interdisciplinary plan of care stated, ""Blood pressure in right arm only due to resident request."" During an interview on 03/30/11 at 8:00 a.m., the administrator (Employee #1) acknowledged that the resident's current interdisciplinary plan of care and the ""Plan of Care"" card contained conflicting instructions for the care of Resident #58. She stated the ""Plan of Care"" card was correct, and the formal interdisciplinary care plan was in error. Employee #1 subsequently provided a facility form entitled ""CHANGE IN HSW ASSIGNMENT SHEET REQUEST"". She offered this form as the tool used to ensure the information on the residents' ""Plan of Care"" cards was updated when necessary. The form had spaces for: * Resident name * Change requested * Staff requesting change and giving it to their supervisor * Date submitted to supervisor / designated nurse * Handwritten in HSW book by______ * RN / Staff / Supervisor that changed the care plan in the computer * Office assistant receiving request, date received, date revised and replaced on unit. She stated that changes can be temporarily made in handwritten form until the office assistants can change the card in the computer. -- b) Resident #60 When the ""Plan of Care"" card, the interdisciplinary care plan, and the physician's orders [REDACTED].#11 PUT CLOTHES IN HAMPER IN HER ROOM - PUT BEDDING / TOWELS IN WITH HIPSTERS FOR WASHING."" The interdisciplinary care plan did not contain this instruction. A physician's orders [REDACTED]. (name) on rounds. Clothes do not have to be washed in house, order discontinued. Dr. (name) stated washing clothes in house is not helping skin rash. Follow up with dermatology, consult is already ordered and scheduled."" A ""CHANGE IN HSW ASSIGNMENT SHEET REQUEST"" was found for Resident #60. The requested change was: ""Discontinue (D/C) wash clothes, bedding and (&) towels in house ...."" The date submitted was 03/11/11. There was a dated signature indicating the instruction was changed in handwritten form on the ""Plan of Care"" card on 03/11/11. There was a signature attesting that the change had been made in the computer and a revised card was placed on unit on 03/14/11. Beside the ""Change requested"" area of the form was written in red ink: ""Discontinue (D/C) #11."" Review of the ""Plan of Care"" card, with a revision date of 03/14/11, found intervention #11 was still printed on the card. Despite the use of the change requested form, the needed change had not been accomplished, resulting in inaccurate instruction for the HSW caring for Resident #60. -- c) Resident #56 Comparison of Resident #56's current interdisciplinary plan of care, current ""Plan of Care"" card, and active physician's orders [REDACTED]. There was an active physician's orders [REDACTED]. Both orders were found on the current ""Plan of Care"" card. Although the current interdisciplinary care plan included the concern of potential for skin breakdown, these two (2) physician's orders [REDACTED]. A current physician's orders [REDACTED]. The ""Plan of Care"" card included intervention #7, which stated the resident was to receive 8 ounces of Glucerna three-times-a-day with meals. Review of the resident's dietary intake record for March 2011 found documentation to reflect the resident had been receiving the supplement three-times-a-day with meals, contrary to the physician's orders [REDACTED]. .",2014-07-01
11092,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-04-12,224,D,1,0,GFJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide mouth care to one (1) of thirteen (13) sampled residents who required extensive physical assistance from staff to meet his personal hygiene needs. Review of the facility's internal grievance / complaint records revealed an allegation of neglect that had been reported to the social worker on 02/14/11, related to Resident #2 not receiving care, including mouth care. The facility's internal investigation included obtaining statements from two (2) nursing assistants, both of whom admitted to not providing Resident #2 mouth care, believing this was not to be done because the resident was ""NPO"" (to receive nothing by mouth). Subsequent interviews with the director of nursing (DON) and the administrator revealed they were not aware of these statements, and there was no evidence the facility had provided training to staff on the need to provide mouth care for residents who were NPO. Resident identifier: #2. Facility census: 112. Findings include: a) Resident #2 1. Review of the facility's ""Customer first concern / grievance reports"" revealed a grievance reported by the social worker (Employee #123), dated 02/14/11, documenting: ""Family states that when they came to visit resident had not received care yet, (symbol for 'no') mouth care."" The facility's resolution to this concern was documented as: ""... CNA's state mouth care was not given because he is NPO (nothing by mouth)..."" Employee #123 investigated the allegation and obtained written statements from two (2) nursing assistants, during which they admitted they did not provide mouth care, believing it was not to be done because the resident was NPO. Employee #55's statement said, ""I have not brushed resident's teeth, he's NPO."" Employee #39's statement said, ""I have not brushed resident's teeth, NPO."" After this investigation was completed, there was no evidence the facility had inserviced staff on the provision of mouth care to residents who are NPO. -- 2. Review of Resident #2 ' s assessment instrument revealed this 78-year year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -- 3. The director of nursing (DON), when interviewed on 04/11/11 at 4:40 p.m., stated he had no knowledge of the grievance, saying, ""Just because a resident is NPO this does not mean they would not get mouth care."" The DON stated he would ""inservice the staff immediately and report the allegation."" -- 4. The administrator confirmed on 04/12/11 at 11:30 a.m. that he also was not aware of the statements made by the nursing assistants. .",2014-08-01
11093,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-04-12,225,E,1,0,GFJO11,". Based on record review, staff interview, and review of facility policy, the facility failed to immediately report allegations of abuse / neglect to the facility's administrator and to State officials as required by law. This was true for seven (7) of twenty-five (25) grievance / concern forms reviewed for the past three (3) months, each of which contained allegations of abuse and/or neglect. Resident identifiers: #60, #43, #29, #2, and #113. Facility census: 112. Findings include: a) Resident #60 Review of the facility's ""Customer first concern / grievance report"" revealed a grievance, dated 02/16/11, documenting: ""Resident stated that CNA (certified nursing assistant) was rough w/ (with) him and threw him into his bed."" During an interview with Employee #123 (social worker) on 04/11/11 at 1:30 p.m., she stated she had investigated the incident. Employee #123 provided written statements from the investigation; however, she stated she had not reported the allegation to any of the State agencies. -- b) Resident #43 Review of the facility's ""Customer first concern / grievance reports"" revealed a grievance, dated 01/10/11, documenting: ""Resident stated she asked for her pain med. (medication) at approx (approximately) 7 am and didn't receive it until 10 am. Roommate laid in poop and had poop all over her bathroom."" During an interview with Employee #123 on 04/11/11 at approximately 1:30 p.m., she verified she had investigated the allegations, and she provided statements from staff and medical record documentation to support her findings; however, she stated she had not reported the allegation to any of the State agencies. -- c) Resident #29 Review of the facility's ""Customer first concern / grievance reports"" revealed a grievance, dated 01/21/11, documenting: ""Resident stated she was changed @ (at) midnight. Then put her call light on @ 3am - no one came until 6am."" During an interview with Employee #123 on 04/11/11 at 1:30 p.m., she provided written documentation of the facility's investigation of the allegation; however, she stated she had not reported the allegation to any of the State agencies. - d) Resident #2 Review of the facility's ""Customer first concern / grievance reports"" revealed a grievance, dated 02/14/11, documenting: ""Family states that when they came to visit resident had not received care yet, (symbol for 'no') mouth care."" The facility's resolution to this concern was documented as: ""... CNA's state mouth care was not given because he is NPO (nothing by mouth)..."" Employee #123, when interviewed at approximately 1:30 p.m. on 04/11/11, verified she failed to report this incident to any of the State agencies. The director of nursing (DON), when interviewed on 04/11/11 at 4:40 p.m., stated he had no knowledge of the grievance, saying, ""Just because a resident is NPO this does not mean they would not get mouth care."" The DON stated he would ""inservice the staff immediately and report the allegation."" -- e) Resident #113 Review of the facility's ""Customer first concern / grievance reports"" revealed three (3) separate allegations made by Resident #113. Two (2) separate allegations were made by Resident #113 on 01/10/11: 1. On 01/10/11 - ""Resident stated that CNA told her Thursday night to shut up, calm down and act like you have sense. Then he shut the door."" The social worker (Employee #123), when interviewed on 04/11/11 at 1:30 p.m., verified she had not reported this allegation of abuse to State officials, including the State nurse aide registry). Employee #123 was aware of the identity of the alleged perpetrator, as she had taken a statement from this employee. 2. On 01/10/11 - ""Resident stated that LPN (licensed practical nurse) told her ""You little tricks don't work did they?..."" Employee #123, when interviewed on 04/11/11 at 1:30 p.m., verified she did not report this allegation to State officials. 3. On 01/06/11 - ""Resident stated that last night the nurse (name of nurse) had a bad tone of voice w/ her. She stated it wasn't what she said, just how she said it. ..."" Employee #123, when interviewed on 04/11/11 at 1:30 p.m., verified she did not report this allegation to State officials. -- f) Review of the facility's policy entitled ""Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property"" revealed, ""The administrator or his/her designee reports alleged violations and substantiated incidents to the state agency and to all other agencies as required."" -- g) On the afternoon of 04/12/11, the administrator, when interviewed about the above allegations made by or on behalf of Residents #60, #43, #2, #29, and #113, stated he was unaware that any of these allegations had been made. .",2014-08-01
11094,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-04-12,323,D,1,0,GFJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to assure a resident's bed alarm, implemented as a safety measure to address falls, was functioning properly. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #6. Facility census: 112. Findings include: a) Resident #6 1. On 04/05/11 at approximately 11:40 p.m., observation found Resident #6 lying on the floor beside his bed. The survey team called for staff assistance. A certified nursing assistant (CNA - Employee #35) was the first to respond to the resident's room, followed by another CNA (Employee #9) and a licensed practical nurse (LPN - Employee #96). Further observation revealed the bed alarm on Resident #6's bed failed to activate. Employee #35, when interviewed, verified the alarm was not working, stating, ""It must need a battery."" Employee #9 replaced the battery and tested the the alarm. The alarm still failed to operate. Employee #9 stated the facility required staff to date the alarm pad when replaced, because the ""alarms are only good for 90 days."" Employee #9 was unable to verify how long this alarm had been in use, because the pad had not been dated. Employee #96 had just started her shift and had not checked the alarm for Resident #6. Subsequent review of the incident / accident report revealed the resident sustained [REDACTED]. -- 2. Medical record review revealed Resident #6, a [AGE] year old male admitted to the facility on [DATE], had admitting [DIAGNOSES REDACTED]. Further review of his medical record revealed a physician's orders [REDACTED]. Check placement and function QS. Replace pad every 90 days and battery PRN (as needed). Every shift everyday."" -- 3. Review of facility's policy for evaluation of alarms revealed, ""The licensed nurse / designee checks placement and function of alarms each shift..."" -- 4. The director of nursing (DON - Employee #120), when interviewed on 04/12/11 at 11:45 a.m., verified the manufacturer required the alarm pad to be replaced every ninety (90) days. He stated the manufacturer provided a space for staff to write in the date when the alarm is activated. He further stated it was the duty of the licensed nurse or designee to check the placement and functionality of alarms on each shift. .",2014-08-01
11095,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-04-14,272,D,1,0,YXF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to conduct an accurate assessment of the skin condition of one (1) of four (4) sampled residents. According to a nursing assessment completed on 03/01/11, Resident #103 had an open area on admission to the facility. The presence of this wound was not identified on the resident's admission minimum data set (MDS) or 14-Day Medicare MDS. When it was first encoded on the resident's 30-Day Medicare MDS, it was identified as a ""Stage 3"" wound. Resident identifier: #103. Facility census: 96. Findings include: a) Resident #103 Review of the nursing assessment completed on admission (dated 03/01/11) revealed Resident #103, a [AGE] year old female who weighed 124 pounds, had skin breakdown located in the ""split in crease of buttocks 7.5 (centimeters or cm) by 0.2 (cm) by 0.1 (cm)"". The nursing admission note, also dated 03/01/11, described the area of skin breakdown as: ""Long split in skin in crease of buttocks 7 1/2 cm x 0.2 (cm) x 0.1 (cm) (sic) [MEDICATION NAME] applied."" Further record review revealed the following descriptions in a Skin Report / Weekly Update for Non-Pressure Related Areas dated 03/01/11: ""red center /c (with) yellow edges"" and ""skin is split"". The treatment plan recorded on this form included measuring the area every six (6) days until healed and applying [MEDICATION NAME] Cream to the area every shift and as needed. Size clarification found in the Skin Report / Weekly Update dated 03/01/11 stated the dimensions of the wound as follows: length - 7.5 cm, width - 0.2 cm, and depth - 0.1 cm. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 03/08/11 found the assessor coded Resident #103 as having no unhealed pressure ulcers upon admission and no other skin problems other than the surgical wound from the [MEDICAL CONDITION] repair. Review of the Care Area Assessment - Pressure Ulcer(s) Worksheet, dated 03/08/11, found ""existing pressure ulcer(s)"" was not marked, with the following notation: ""No pressure ulcers present."" Review of extensive risk factors in the Pressure Ulcer(s) Worksheet also found no mention that Resident #103 was admitted with an open area in the crease of her buttocks measuring 7 1/2 cm x 0.2 cm. x 0.1 cm. In the 14-Day MDS with an ARD of 03/16/11, the assessor coded her as having no unhealed pressure ulcers but having an open lesion other than an ulcer. In comparison, in the 30-Day MDS with an ARD of 03/30/11, the assessor coded her as having a Stage 3 pressure ulcer measuring 3.0 cm in length, 5.0 cm in width, and 0.2 cm in depth, which the assessor now noted was present on admission. Similarly, the discharge MDS dated [DATE] also coded her as having a Stage 3 pressure ulcer that was present upon admission. During an interview with the staff development nurse (Employee #143) on 04/14/11 at 3:40 p.m., she agreed that the 14-Day MDS (dated 03/16/11) coded the resident as having no pressure ulcers and the 30-Day MDS (dated 03/30/11) coded her as having a Stage 3 pressure ulcer that was present on admission. During an interview with the assessment nurse (Employee #120) on 03/14/11 at 4:00 p.m., she said she did not encode the admission MDS (dated 03/08/11) to reflect the resident had a pressure ulcer on admission, because it seemed to be a crack between her buttocks. She looked at the Wound / Skin Healing Record dated 03/24/11, noting the wound was identified as a Stage 2 pressure ulcer to the coccyx on that form, and said it looks like the pressure ulcer developed in house and got worse while she was here, because the wound was not assessed as having been a pressure ulcer on admission. Employee #120 agreed it was not coded as a pressure ulcer on the 14-Day MDS, and she did not see any other measurements of the wound's dimension from admission until 03/24/11. The administrator, who was present at this time, agreed that whatever type of wound it was, it should have been measured and documented every week, and it was not. .",2014-08-01
11096,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-04-14,279,D,1,0,YXF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of facility's policies / procedures, the facility failed to develop a comprehensive care plan that identified the presence of a pressure ulcer, to include assessing its stage and planning for treatment and monitoring of the ulcer as it declined from a Stage II to a Stage III wound, for one (1) of four (4) sampled residents. Resident identifier: #103. Facility census: 96. Findings include: a) Resident #103 Review of the nursing assessment completed on admission (dated 03/01/11) revealed Resident #103, a [AGE] year old female who weighed 124 pounds, had skin breakdown located in the ""split in crease of buttocks 7.5 (centimeters or cm) by 0.2 (cm) by 0.1 (cm)"". The nursing admission note, also dated 03/01/11, described the area of skin breakdown as: ""Long split in skin in crease of buttocks 7 1/2 cm x 0.2 (cm) x 0.1 (cm) (sic) [MEDICATION NAME] applied."" Further record review revealed the following descriptions in a Skin Report / Weekly Update for Non-Pressure Related Areas dated 03/01/11: ""red center /c (with) yellow edges"" and ""skin is split"". The treatment plan recorded on this form included measuring the area every six (6) days until healed and applying [MEDICATION NAME] Cream to the area every shift and as needed. Size clarification found in the Skin Report / Weekly Update dated 03/01/11 stated the dimensions of the wound as follows: length - 7.5 cm, width - 0.2 cm, and depth - 0.1 cm. Review of the resident's medical record found a late entry in nursing progress notes, which was written on 03/28/11 for 03/24/11, stating, ""Resident exhibits Stage III area to coccyx. Area measures 3.0 cm by 5.0 cm x 0.2 cm (sic) Center of wound dark red /c small amount serosanguinous drainage. Surrounding skin bright red & irritated. Area cleansed /c NS (normal Saline), Fiboral packed to coccyx area & Allevyn dressing applied."" Further clarification in the Wound / Skin Healing Record dated 03/24/11 revealed the wound was a pressure ulcer on the coccyx measuring 3.0 cm in length, 5.0 cm in width, and 0.2 cm in depth; the date of onset was left blank on the form, and the ""original stage"" was identified as ""Stage II"". Review of the comprehensive care plan revealed, on pages 10 and 11, the resident ' s skin problem consisted of a ""small open area between buttocks due to moisture"" and also noted the resident was: ""At risk for additional skin breakdown secondary to need for extensive assistance with bed mobility, non-amb (ambulatory) at this time; frequent urinary and occasional bowel incontinence."" Further review of the care plan revealed no care plan revisions or assessments that identified the stage of the pressure ulcer or the changing size or character of the pressure ulcer. Care plan review also revealed no specific interventions targeted at healing or monitoring an existing pressure ulcer. During an interview on 04/14/11 at 3:00 p.m., during which concerns related to assessment and monitoring of pressure ulcers, the coding of ulcers on the minimum data set assessments and care planning were discussed, the administrator offered to provide policies on wound assessments and monitoring. Review of the Wound Care / Documentation form, produced by the administrator on 04/14/11 at 3:30 p.m., found that wounds were to be assessed on admission and measured, orders for dressing(s) were to be placed on the treatment record, appropriate preventative measures were to implemented, and the instruction listed under Item #7 identified the need to address the wound in the resident's care plan. .",2014-08-01
11097,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-04-14,282,D,1,0,YXF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and policy review, the facility failed to follow its own policy regarding wound monitoring and assessment; and failed to follow physician's orders [REDACTED]. Resident identifier: #103. Facility census: 96. Findings include: a) Resident #103 1. Review of the nursing assessment completed on admission (dated 03/01/11) revealed Resident #103, a [AGE] year old female who weighed 124 pounds, had skin breakdown located in the ""split in crease of buttocks 7.5 (centimeters or cm) by 0.2 (cm) by 0.1 (cm)"". The nursing admission note, also dated 03/01/11, described the area of skin breakdown as: ""Long split in skin in crease of buttocks 7 1/2 cm x 0.2 (cm) x 0.1 (cm) (sic) [MEDICATION NAME] applied."" Further record review revealed the following descriptions in a Skin Report / Weekly Update for Non-Pressure Related Areas dated 03/01/11: ""red center /c (with) yellow edges"" and ""skin is split"". The treatment plan recorded on this form included measuring the area every six (6) days until healed and applying [MEDICATION NAME] Cream to the area every shift and as needed. Size clarification found in the Skin Report / Weekly Update dated 03/01/11 stated the dimensions of the wound as follows: length - 7.5 cm, width - 0.2 cm, and depth - 0.1 cm. -- 2. Review of Resident #103's medical record found only one (1) other measurement was completed during this resident's month long stay at the facility, other than the measurement recorded in admission assessment on 03/01/11. A late entry in nursing progress notes, which was written on 03/28/11 for a 03/24/11 assessment, stated, ""Resident exhibits Stage III area to coccyx. Area measures 3.0 cm by 5.0 cm x 0.2 cm (sic) Center of wound dark red /c small amount serosanguinous drainage. Surrounding skin bright red & irritated. Area cleansed /c NS (normal Saline), Fiboral packed to coccyx area & Allevyn dressing applied."" Further clarification in the Wound / Skin Healing Record dated 03/24/11 revealed the wound was a pressure ulcer on the coccyx measuring 3.0 cm in length, 5.0 cm in width, and 0.2 cm in depth; the date of onset was left blank on the form, and the ""original stage"" was identified as ""Stage II"". -- 3. Review of the treatment administration record (TAR) revealed a treatment to: ""Measure split in crease of buttocks q (every) 6 days till (sic) healed."" This was marked off on the TAR with a rectangular box to prompt the nurse to initial as having recorded wound measurements on the 3-11 shift on 03/01/11, 03/07/11, 03/13/11, 03/19/11, 03/25/11, and 03/31/11. However, review of the TAR found it was initialed as having been done only on 03/01/11, and not on any of the other dates. Further record review found the wound was measured only on 03/01/11 (upon admission) and again on the 7-3 shift by a wound care nurse on 03/24/11. As cited above, the wound care nurse described the wound in nurse's progress notes as a Stage III area to the coccyx on 03/24/11. -- 4. During interview with a wound care nurse (Employee #136) on 04/14/11 at 12:15 p.m., she agreed the TAR was initiated on 03/01/11 to measure the wound every six (6) days until healed, but it was marked as having not been done on 03/07/11, 03/13/11, and 03/19/11, and that measurements were not completed on those three (3) dates. She acknowledged that her assessment and measurement of the wound on 03/24/11 was the only one (1) completed during the resident's stay at the facility since the day of her admission. -- 5. Review of physician's orders [REDACTED]. However, review of the TAR revealed that, after the treatment was completed on 03/18/11, the dressing was due again to be changed on 03/21/11; but the treatment was not completed on 03/21/11 as signified by a rectangular box with an ""x"" through it; instead, the dressing change was completed on Day 4. Review of the reverse side of the TAR found no mention of why this treatment was not completed timely as ordered by the physician. Also, review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on the reverse side of any of the three (3) TARs, as they were all left blank. -- 6. Review of physician's orders [REDACTED]. Review of the TAR revealed it was initialed as having been measured on 03/24/11. Boxes were drawn in which to initial the measurement on the 7-3 shift on 03/30/11 and 03/31/11; however, both boxes had ""x's"" in them, signifying the coccygeal wound was not measured. Review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on back of the TAR, leaving it blank. -- 7. Review of the wound care policy, supplied by the administrator on 04/14/11 at approximately 3:30 p.m., revealed the Wound / Skin Healing Record and/or the Skin Report / Weekly Update must include documentation addressing the following: - what kind of wound - measurements - dressing and frequency to change - location - odor - amount of drainage - type of drainage - surrounding tissue - wound edges - wound bed During interview with the administrator on 04/14/11 at approximately 3:30 p.m., she said measurements of all wounds were supposed to be done weekly and as needed. .",2014-08-01
11098,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-04-14,314,G,1,0,YXF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and policy review, the facility failed, for one (1) of four (4) sampled residents, to ensure a resident admitted with a pressure sore received necessary treatment and services to promote wound healing, by failing to: (1) monitor, assess, and record the characteristics of the pressure sore in accordance with physician orders [REDACTED]. integrity on the resident assessment instruments; and (4) develop a resident-specific care plan to address the wound, and revise the care plan when the status of the wound declined. Resident #103 was admitted on [DATE] and discharged on [DATE]. The pressure sore on Resident #103's coccyx declined from a Stage II area measuring 7.5 cm x 0.2 cm x 0.1 cm (present on admission), to a Stage III area measuring 3.0 cm x 5.0 cm x 0.2 cm on 03/24/11. There was no documentation to reflect any assessment / monitoring of this area between 03/01/11 and 03/24/11, nor was the documentation to reflect any assessment / monitoring of this area after 03/24/11 or prior to her discharge on 04/01/11. Resident identifier: #103. Facility census: 96. Findings include: a) Resident #103 1. Review of the nursing assessment completed on admission (dated 03/01/11) revealed Resident #103, a [AGE] year old female who weighed 124 pounds, had skin breakdown located in the ""split in crease of buttocks 7.5 (centimeters or cm) by 0.2 (cm) by 0.1 (cm)"". The nursing admission note, also dated 03/01/11, described the area of skin breakdown as: ""Long split in skin in crease of buttocks 7 1/2 cm x 0.2 (cm) x 0.1 (cm) (sic) [MEDICATION NAME] applied."" Further record review revealed the following descriptions in a Skin Report / Weekly Update for Non-Pressure Related Areas dated 03/01/11: ""red center /c (with) yellow edges"" and ""skin is split"". The treatment plan recorded on this form included measuring the area every six (6) days until healed and applying [MEDICATION NAME] Cream to the area every shift and as needed. Documentation on the Skin Report / Weekly Update dated 03/01/11 also provided the following dimensions of the wound: length - 7.5 cm, width - 0.2 cm, and depth - 0.1 cm. Only one (1) other measurement of the resident's pressure sore was completed during this resident's month long stay at the facility, which was recorded in a late entry nursing progress note written on 03/28/11 for 03/24/11. This entry stated, ""Resident exhibits Stage III area to coccyx. Area measures 3.0 cm by 5.0 cm x 0.2 cm (sic) Center of wound dark red /c small amount serosanguinous drainage. Surrounding skin bright red & irritated. Area cleansed /c NS (normal Saline), Fiboral packed to coccyx area & Allevyn dressing applied."" Documentation on the Wound / Skin Healing Record dated 03/24/11 also revealed provided the following measurements for this pressure ulcer on the resident's coccyx: length - 3.0 cm, width - 5.0 cm, and depth - 0.2 cm. The date of onset of the wound was left blank on the form, and the ""original stage"" was identified as ""Stage II"". -- 2. Review of the treatment administration record (TAR) revealed a physician's orders [REDACTED]."" The TAR was marked with rectangular boxes to prompt the nurse to initial after obtaining wound measurements on the 3-11 shift on 03/01/11, 03/07/11, 03/13/11, 03/19/11, 03/25/11, and 03/31/11. However, review of the TAR found it was initialed to indicate this order was carried out only on 03/01/11, and not on any of the other dates. Further record review found the wound was measured only on 03/01/11 (upon admission) and again on the 7-3 shift by a wound care nurse on 03/24/11. As cited above, the wound care nurse described the wound in nurse's progress notes as a Stage III area to the coccyx on 03/24/11. -- 3. In an interview with a wound care nurse (Employee #136) on 04/14/11 at 12:15 p.m., she said the floor nurses typically initiate a Wound / Skin Healing Record form whenever a pressure ulcer is identified, and they place that form in the Medication Administration Record, [REDACTED]. However, this form was not initiated for Resident #103 upon her admission to the facility. When asked about the documentation on the TAR, she agreed the order on the TAR was initiated on 03/01/11 to measure the wound every six (6) days until healed and that the TAR was not marked to indicate this order was carried out on 03/07/11, 03/13/11, and 03/19/11. She acknowledged that wound measurements were not taken on those three (3) dates. She also acknowledged that her assessment and measurement of the wound on 03/24/11 was the only one (1) completed during the resident's stay at the facility since the day of her admission on 03/01/11. When asked why the wound was not measured again after 03/24/11 and why it was not measured on 04/01/11 (prior to the resident's discharge to home), she said any of the nurses can and do measure and record information about a resident's pressure ulcers. She reported that she was the individual who used to measure all of the residents' wounds weekly, but it was decided instead that the floor nurses would do measurements on their own residents. She said sometimes the floor nurses forego measuring the wounds if they know a wound care nurse will be there to assess in the near future. -- 4. During an interview with the nurse manager (Employee #141) on 04/14/11 at 5:20 p.m., she reviewed Resident #103's nurse's progress notes and found an entry dated 03/08/11, which stated the area in the crease of the Resident's buttocks was not improving. She also found an entry dated 03/18/11, which cited the physician was in the facility and a new dressing was started for the wound ""due to worsening"". Review of the physician's medication / order sheet dated 03/18/11 found an area to record the indication or [DIAGNOSES REDACTED]. -- 5. Review of physician's orders [REDACTED]. Review of the TAR revealed that, after the treatment was completed on 03/18/11, the dressing was due to be changed again on 03/21/11. The treatment was not completed as ordered on [DATE], as signified by a rectangular box with an ""x"" through it; instead, the dressing change occurred on 03/22/11. Review of the reverse side of the TAR found no explanation as to why this treatment was not completed timely as ordered by the physician. Also, review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on the reverse side of any of the three (3) TARs, as they were all left blank. -- 6. Review of physician's orders [REDACTED]. Review of the TAR revealed it was initialed to indicate the wound was measured on 03/24/11. Boxes were drawn in which to initial that measurements were obtained on the 7-3 shift on 03/30/11 and 03/31/11; however, both boxes had ""x's"" in them, signifying the coccygeal wound was not measured on these dates. Review of the reverse side of the TAR found a Treatment Record for staging the pressure area, recording the dimensions and appearance of the area, and any other comments; however, nothing was completed on back of the TAR, leaving it blank. -- 7. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 03/08/11 found the assessor coded Resident #103 as having no unhealed pressure ulcers upon admission and no other skin problems other than the surgical wound from the [MEDICAL CONDITION] repair. In the 14-Day MDS with an ARD of 03/16/11, the assessor coded her as having no unhealed pressure ulcers but having an open lesion other than an ulcer. In comparison, in the 30-Day MDS with an ARD of 03/30/11, the assessor coded her as having a Stage 3 pressure ulcer measuring 3.0 cm in length, 5.0 cm in width, and 0.2 cm in depth, which the assessor now noted was present on admission. Similarly, the discharge MDS dated [DATE] also coded her as having a Stage 3 pressure ulcer that was present upon admission. During an interview with the staff development nurse (Employee #143) on 04/14/11 at 3:40 p.m., she agreed that the 14-Day MDS (dated 03/16/11) coded the resident as having no pressure ulcers and the 30-Day MDS (dated 03/30/11) coded her as having a Stage 3 pressure ulcer that was present on admission. During an interview with the assessment nurse (Employee #120) on 03/14/11 at 4:00 p.m., she said she did not encode the admission MDS (dated 03/08/11) to reflect the resident had a pressure ulcer on admission, because it seemed to be a crack between her buttocks. She looked at the Wound / Skin Healing Record dated 03/24/11, noting the wound was identified as a Stage 2 pressure ulcer to the coccyx on that form, and said it looks like the pressure ulcer developed in house and got worse while she was here, because the wound was not assessed as having been a pressure ulcer on admission. Employee #120 agreed it was not coded as a pressure ulcer on the 14-Day MDS, and she did not see any other measurements of the wound's dimension from admission until 03/24/11. The administrator, who was present at this time, agreed that whatever type of wound it was, it should have been measured and documented every week, and it was not. Review of the Care Area Assessment - Pressure Ulcer(s) Worksheet, dated 03/08/11, found ""existing pressure ulcer(s)"" was not marked, with the following notation: ""No pressure ulcers present."" Review of extensive risk factors in the Pressure Ulcer(s) Worksheet also found no mention that Resident #103 was admitted with an open area in the crease of her buttocks measuring 7 1/2 cm x 0.2 cm. x 0.1 cm. -- 8. Review of the comprehensive care plan revealed, on pages 10 and 11, the resident's skin problem consisted of a ""small open area between buttocks due to moisture"" and also noted the resident was: ""At risk for additional skin breakdown secondary to need for extensive assistance with bed mobility, non-amb (ambulatory) at this time; frequent urinary and occasional bowel incontinence."" Further review of the care plan revealed no care plan revisions or notations that identified the stage of the pressure ulcer or the changing size or character of the pressure ulcer. Care plan review also revealed no specific interventions targeted at healing or monitoring the existing pressure ulcer. -- 9. On 04/14/11 at 3:00 p.m., concerns related to assessment and monitoring of pressure ulcers, the coding of ulcers on the minimum data set assessments (MDS), and care planning were discussed with the administrator, who then offered to provide policies on wound assessments and monitoring. Review of the Wound Care / Documentation form, produced by the administrator on 04/14/11 at 3:30 p.m., found that wounds were to be assessed on admission and measured, orders for dressing(s) were to be placed on the treatment record, appropriate preventative measures were to implemented, and the instruction listed under Item #7 identified the need to address the wound in the resident's care plan. Review of the wound care policy revealed the Wound / Skin Healing Record and/or the Skin Report / Weekly Update must include documentation addressing the following: - what kind of wound - measurements - dressing and frequency to change - location - odor - amount of drainage - type of drainage - surrounding tissue - wound edges - wound bed During an interview with the administrator on 04/14/11 at approximately 3:30 p.m., she said measurements of all wounds were supposed to be done weekly and as needed.",2014-08-01
11099,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-06-07,309,D,1,0,YXF812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and policy review, the facility failed to provide treatment as directed by a physician's order on 06/04/11. Resident #23 had a physician's order for treatment of [REDACTED]. This occurred for one (1) of ten (10) sampled residents. Facility census: 89. Findings include: a) Resident #23 A review of the treatment record for Resident #23 found it was blank for the date of 06/04/11. Review of the treatment record with the director of nursing (DON), on 06/07/11 at 10:00 a.m., found the treatment for 06/04/11 was not completed. The DON said the nurse told her she did not have time to do the treatments for that date, and she provided documentation of disciplinary action that was given to the nurse. The ordered treatment, clarified by the physician on 03/30/11, was: ""Medi-honey with gauze to L (left) Great Toe qd (daily)."" A nurse manager (Employee #97), when interviewed on the mid-morning of 06/07/11, said treatment records were to be checked with the nurse from the other unit, to verify that treatments are marked off as having been completed by the nurse who was assigned to the residents. The nurse from the other hallway was to sign the Treatment Completion Log to indicate that treatments were documented as completed. Review of the Treatment Completion Log for 06/04/11 found it was signed off by a licensed practical nurse (LPN - Employee #104) and then marked through and initialed by the same nurse. The facility's ""Skin / Documentation Protocol"" (revised 04/28/11) stated, ""**NURSE WILL CHECK THE OPPOSITE UNIT TREATMENT BOOK TO ASSURE TREATMENTS WERE DONE AS ORDERED PER PROTOCOL."" .",2014-08-01
11100,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-06-07,441,D,1,0,YXF812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, medical record review, and a review of facility policies for dressing changes, the facility failed to maintain an effective infection control program for two (2) of ten (10) sampled residents. Resident #12's bathroom door was found with four (4) isolation gowns hanging on it. During a treatment observation, Resident #1's open wound (which was located on the spine of the resident's mid-back) was allowed to make contact with a contaminated surface four (4) times. Findings include: a) Resident #12 Record review revealed this resident was in isolation for Clostridium difficile (C diff) and was receiving the antibiotic [MEDICATION NAME]. The resident was having multiple loose bowel movements during the afternoon shift on 06/06/11, per an interview at 7:30 p.m. with the resident's wife. Observation of Resident #12's room on 06/06/11 at 7:45 p.m., with a nurse manager and a licensed practical nurse (Employees #97 and #123, respectively) found four (4) cloth isolation gowns on an over-the-door hanger on the inside of the resident's bathroom door. Employee #97 removed the gowns from the room and reported Employee #123 had previously worn one (1) of the gowns on but did not touch anything in the room with it. Employee #123 put on an isolation gown from an overbed table located inside of the room where other isolation supplies were located. An nursing assistant (Employee #138) also donned an isolation gown and retrieved one (1) from a place outside of the room for the surveyor. After the observation of the treatment for [REDACTED].#138 removed her isolation gown and left the room with it. When questioned as to where the contaminated gowns were taken (as there was no receptacle in the room in which to place soiled linens and gowns), Employee #138 stated they were taken to the soiled utility room that was next door and placed with the rest of the laundry, as all the laundry is considered contaminated and would be sanitized. She then took the soiled gown out of the resident's room and went into the soiled utility room. An interview with the director of nursing (DON), on the early afternoon of 06/07/11, found that a soiled linen container should have been used to transport any soiled linens or cloth isolation gowns. A review of the facility's Infection Control Manual (no date given) found: ""Protective clothing contaminated with blood or body fluids, secretions or excretions should be placed and transported in bags or containers that prevent leakage. Personnel involved in bagging, transport, and laundering of contaminated clothing should wear gloves."" During the mid-morning on 06/07/11, observation of Resident #12's room found a receptacle located within the room for soiled linens and gowns. -- b) Resident #1 Observation, during a dressing change by a licensed practical nurse (LPN - Employee #1) on 06/07/11 at 10:00 a.m., found Resident #1 had an open area to the mid-back located on the spine. The resident was sitting up in a recliner with a foam mattress under her which was covered with a duvet. The wound was approximately 0.6 cm x 0.5 cm in size. The nurse used normal saline and 4 x 4 gauze to cleanse the wound, but she did not place any barrier behind the resident's back. Each time the nurse cleansed the resident's back, the resident was allowed to sit against the duvet cover, recontaminating the open wound. This occurred three (3) times. The nurse then placed a prism dressing on the resident's back with an Allevyn dressing that did not cover the prism. She removed the dressing and went out to the cart to get more supplies, allowing the resident again to sit back against the duvet cover and recontaminating the resident's wound a fourth time. On the early afternoon of 06/07/11, the DON provided a copy of the facility's policy titled ""Dry Clean Dressing"" (dated 2001 and revised March 2005). She stated the policy did not direct staff to place a barrier under a resident prior to completing a dressing change. She also reviewed the facility's policy titled ""Sterile Dressing Change"" with the surveyor and stated it also did not direct staff to place a barrier under the resident prior to completing a sterile dressing change. The DON noted that maybe the policy needed to be revised. .",2014-08-01
11101,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-06-07,514,D,1,0,YXF812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and medical record review, the facility failed ensure each resident's medical record was accurate and complete. Resident #23 had a physician's orders [REDACTED]. Resident #23 also had monthly physician's recapitulation orders for June 2011 which did not identify which foot was to receive a treatment to the great toe. This occurred for one (1) of ten (10) sampled residents. Facility census: 89 Findings included: a) Resident #23 1. A review of the treatment record for Resident #23 found it was blank for the dates of 06/01/11 and 06/02/11. The ordered treatment, clarified by the physician on 03/30/11, was: ""Medi-honey with gauze to L (left) Great Toe qd (daily)."" Review of the treatment record with the director of nursing (DON), on 06/07/11 at 10:00 a.m., found the treatments were completed but the treatment record was not signed off for these dates. -- 2. The 03/30/11 clarification physician's orders [REDACTED]."" Review of the June 2011 monthly recapitulation of physician's orders [REDACTED]."" The recapitulation order did not identify which foot was to receive treatment. .",2014-08-01
11102,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-06-07,520,E,1,0,YXF812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and policy review, the facility failed to ensure the quality assessment and assurance (QAA) committee developed and implemented appropriate plans of action to correct quality deficiencies of which its members were aware. The facility failed to ensure all aspects of the approved Plan of Correction (POC) were completed by the target date specified by the facility, and failed to revise plans that were not achieving or sustaining the desired outcomes. The facility also did not fully implement their POC as evidenced by their failure to inservice all licensed nurses on proper skin assessment, documentation, following physician orders, and the importance of strict adherence of the facility's wound care policy. These deficient practices affected two (2) of ten (10) sampled residents and had the potential to affect all residents with wound care needs. Resident identifiers: #15 and #23. Facility census: 89. Findings include: a) Resident #15 Record review of newly admitted Resident #15 revealed the presence of a small Stage II pressure ulcer to the left buttock. Review of the medical record found a physician's orders [REDACTED]. Further record review revealed Resident #15's interim care plan did not mention the presence of the Stage II pressure ulcer. (See also citation at F279.) Review of the Wound Care/Documentation sheet (revised 07/16/10 and located on the front section of the treatment log book) revealed: ""Initiate interim Care Plan if new admission or re-admit."" Review of the Skin / Documentation Protocol (revised 04/28/11) found: ""Implement Care Plan and update as needed."" During an interview with the director of nursing (DON) on 06/07/11 at 1:40 p.m., she stated the pressure ulcer should have been included on Resident #15's interim care plan on the day of admission. During an interview with a data entry person (Employee #75) on 06/07/11 at 1:50 p.m., she stated the Health Information Management (HIM) division audits all new admission and re-admission records seventy-two (72) hours after admission; reviews physician's orders [REDACTED]. She said this chart was due today for the 72-hour review to identify anything lacking on the medical record, which would include skin issues on the interim care plan. During an interview with the health information manager (Employee #13) on 06/07/11 at 2:45 p.m., she presented an Episodic Care Plan obtained from the West Virginia Health Care Association (revision date of 2009), targeted specifically for Decubitus ulcers. She stated this form was obtained and reviewed after the facility's mandatory nursing inservice on wound care in April 2011, and nurses had not yet been inserviced on the use of this form. She said this form can be used for newly admitted residents with pressure ulcers. She said this form was adopted for use after the POC was submitted. -- b) Resident #23 A review of the treatment record for Resident #23 found it was blank for the date of 06/04/11. Review of the treatment record with the director of nursing (DON), on 06/07/11 at 10:00 a.m., found the treatment for 06/04/11 was not completed. The DON said the nurse told her she did not have time to do the treatments for that date, and she provided documentation of disciplinary action that was given to the nurse. The ordered treatment, clarified by the physician on 03/30/11, was: ""Medi-honey with gauze to L (left) Great Toe qd (daily)."" A nurse manager (Employee #97), when interviewed on the mid-morning of 06/07/11, said treatment records were to be checked with the nurse from the other unit, to verify that treatments are marked off as having been completed by the nurse who was assigned to the residents. The nurse from the other hallway was to sign the Treatment Completion Log to indicate that treatments were documented as completed. Review of the Treatment Completion Log for 06/04/11 found it was signed off by a licensed practical nurse (LPN - Employee #104) and then marked through and initialed by the same nurse. The facility's ""Skin / Documentation Protocol"" (revised 04/28/11) stated, ""**NURSE WILL CHECK THE OPPOSITE UNIT TREATMENT BOOK TO ASSURE TREATMENTS WERE DONE AS ORDERED PER PROTOCOL."" -- c) Review of the facility's Plan of Correction, which was accepted by the State survey and certification agency on 05/27/11, revealed the facility's plan to mandate all licensed nurses to attend an inservice on proper skin assessment, proper skin care documentation, wound care measurements, and the importance of strict adherence of the facility's wound care policy as well as following physician's orders [REDACTED].) The facility's inservice sign-in roster dated 04/28/11, when compared against an alphabetical listing of facility staff, found the following licensed nurses did not attend the mandatory inservice on 04/28/11: - Employees #12, #22, #36, and #72 were excused; - Employee #109 was not listed; - Employees #115, #127, and #132 did not sign the roster. There was no evidence to reflect that make-up inservicing was offered to these nurses who, for whatever reason, failed to attend the mandatory inservicing. -- During an interview with a nurse unit manager (Employee #97) on 06/07/11 at 3:00 p.m., she acknowledged she had not scheduled a make-up inservice for those licensed nurses who missed the in-service. She said several nurses who missed the inservice were given a packet of material to read. She acknowledged that those employees who received the packet of materials to read did not sign as having received the packet or as having read and understood the materials.",2014-08-01
11103,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2011-04-06,225,E,1,0,SJ4C11,". Based on medical record review, staff interview, review of the facility's internal investigations into allegations of resident abuse / neglect, and review of the facility's abuse policies and procedures, the facility failed to immediately report and/or thoroughly investigate all allegations of abuse / neglect to the State survey agency. Medical record review found allegations of neglect made on behalf of Resident #88 by a family member. There was no evidence to reflect the facility immediately reported or thoroughly investigated these allegations. This occurred for one (1) of fifteen (15) sampled residents. Additionally, the facility discovered that Employee #107 (the former social worker) did not immediately report abuse / neglect allegations and/or provide the results of the facility's internal investigations into these allegations to the State survey agency or State nurse aide registry within a timely manner. The exact number of cases is not known, but this practice affected more than an isolated number of residents. Facility census: 87. Findings include: a) Resident #88 Review of Resident #88's medical record revealed a social services notes dated 02/01/11, stating, ""(Name) pastor and member of Ethics Committee at (name of local hospital) returned SSD's call. Stated daughter was in residents room last night when he entered along with LTC Ombudsman and (name), WV Advocate. Reported daughter was making accusations of poor care at facility in that her mother was 'covered with bed sores.' He stated stated nurse immediately did a full body assessment and reported her skin was 'perfect'. (Name) was concerned about why daughter was 'making false accusations.' Reported if the (sic) have an actual meeting for the ethics consult that he would like SSD to attend if daughter agrees."" An interview with the facility's administrator, on the mid-morning of 04/06/11, found she did attend an ethics committee meeting held at the local hospital for Resident #88. She confirmed the resident's daughter made allegations against the facility, but she was not specific when asked what the allegations were. A copy of the ethics committee meeting notes was requested, and these were not received as of the exit conference on 04/06/11. Review of the facility's internal investigations into allegations of resident abuse / neglect found no information about allegations of neglect having been made by the daughter of Resident #88 prior to or during the ethics committee meeting b) Employee #107 An interview with the administrator, on 04/04/11 at 3:00 p.m., found the former social worker (Employee #107) did not report allegations of abuse / neglect to the State survey agency or the State nurse aide registry in a timely manner. She reported becoming aware of these problems when the social worker quit on 03/18/11, and she (the administrator) began to review the facility's abuse / neglect files on 03/21/11. On the same date (03/21/11), the administrator found pieces of information missing from cases requiring the mandatory reporting. She contacted the regional ombudsman in an effort to identify what information was reported and what was still missing. On 04/06/11 at 1:50 p.m., the administrator provided a letter of explanation addressed to the State survey agency with explanations and time sequences of events. The facility policy titled ""HR 409 Investigation and Reporting of Alleged Violation of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property"" (dated 08/01/99 and revised on 07/01/10), under the heading ""Investigation"", stated: ""Any employee who suspects an alleged violation shall immediately notify the ED (executive director) or his/her designee. The ED shall also notify the appropriate state agency, in accordance with state law, as well as notify the Director of Operations. The results of all investigation must be reported to the ED or his/her designee and to the appropriate state agency, as required by law, within five (5) days of the alleged violation."" The same policy, under the heading ""Investigation"", stated, ""Investigations shall be conducted by the ED, DNS (director of nursing services), or subject matter expert... The investigation shall include interviews of employees, visitors, residents, volunteers and vendors who may have knowledge of the alleged incident. ... The documentation of the investigation shall be kept in the ED's office in a secure administrative file..."" .",2014-08-01
11104,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2011-04-06,441,D,1,0,SJ4C11,". Based on observation, staff interview, and a review of the facility's hand washing policy and procedure, the facility failed to ensure one (1) of three (3) nurses observed during medication administration practiced hand hygiene in accordance with facility policy and procedure. A licensed practical nurse (LPN) turned off the water faucet after washing her hands without first obtaining a clean paper towel, thereby recontaminating her hands. Resident identifier: #35. Facility census: 87. Findings include: a) Resident #35 During the administration of medication to Resident #35 on 04/05/11 at 3:00 p.m., the LPN (Employee #75) washed her hands then turned off the water faucet without first obtaining a paper towel. This occurred three (3) times during the observation. Review of the facility's handwashing policy, with the director of nursing on 04/06/11 at 2:00 p.m., found the nurse should have obtained a paper towel before turning off the water faucet, in order to control the spread of bacteria. The handwashing policy (dated 2006), in the section titled ""Procedure"", stated: ""#12. Use clean disposable hand towel to turn off faucet and to open door if exiting a room.""",2014-08-01
11105,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,155,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, ""I have the insulin the doctor wants you to take,"" but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON) agreed that Employee #35 gave Resident #23 an injection of [MEDICATION NAME] during the incident. - 3. Review of the facility's policy titled ""Against Medical Advice Discharge"" (revised 09/2008), produced by Employee #119 on 04/27/11 at 12:40 p.m., revealed the following statement: ""No capacitated resident will be held in the nursing facility against their wishes, unless with a court order. Any incapacitated resident cannot be responsible for their medical decisions. These residents will not be allowed to leave the facility as they wish."" - 4. Interview with Employee #35, on 04/27/11 at 4:30 p.m., revealed when she came to work at 3:00 p.m. on 03/03/11, Resident #23 was already upset and agitated because his wife had come to the facility and brought him some clothing, but he thought he was going home. The family, however, did not want to take him home. Employee #35 asked Resident #23 if she could give him something to calm his nerves, but he refused, so she backed away with the [MEDICATION NAME]. The resident was on the grounds but outside the fence and was in and out of the facility numerous times during this hour-long episode, and police were on the scene at one point. She called the physician, who allegedly told her he had capacity, so let him leave if he wants to, but she spoke her fear that the resident could enter the highway and get killed, and she would be held liable for manslaughter. She said the physician, then, gave her the order to give the resident [MEDICATION NAME] 0.5 mg. According to Employee #35, while staff distracted the resident and tried to take his cane, she gave the injection of [MEDICATION NAME]. Resident #23 was not held down and was not restrained while the injection was given. - 5. Review of the medical record revealed that, on 03/14/11, the facility's medical director (Employee #81) evaluated the resident and determined that he lacked capacity related to dementia with cognitive loss, disorientation to person / place / time, and the inability to understand or make medical decisions, with expected long-term incapacity. - 6. Review of the attending physician's progress notes, dated 03/18/11, found the attending physician ""did not have him declared as lacking mental capacity and with some coercion he got [MEDICATION NAME] intramuscularly and apparently he settled down. I have seen him in the clinic since then to see if I need to change his mental status evaluation ... and I did not change it."" - 7. During an interview with Resident #23 on 04/27/11 at 4:45 p.m., he said he recalled being mad once when they (facility staff) would not let him leave when he wanted to go home. He did not have clear recall about any injections other than insulin, and he said he had never been hurt by anyone at the facility. .",2014-08-01
11106,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,225,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review, the facility failed to immediately report, in accordance with State law, an alleged violation involving resident abuse / mistreatment involving one (1) of six (6) sampled residents who possessed capacity and who received an injection of a benzodiazapine drug ([MEDICATION NAME]) without his consent. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was offered an injection which he refused on 03/03/11, but the nurse soon afterward gave the injection without first telling the resident what she was going to do and obtaining his consent. During an interview with the nurse (Employee #35) on 04/27/11 at 4:30 p.m., she said she called and obtained a physician's orders [REDACTED].#23 an injection of [MEDICATION NAME] when he was trying to leave the facility, because she feared he might go out to the road and get killed. She said facility staff distracted the resident and she gave the injection intramuscularly at approximately 4:00 p.m. on 03/03/11. Record review found the facility completed an incident report on 03/04/11; an Adult Protective Service Report on 03/14/11; a complaint report to the West Virginia State Board of Examiners for Licensed Practical Nurses on 03/17/11; and there was a fax cover sheet to the State survey and certification agency (Office of Health Facility Licensure and Certification - OHFLAC) dated 03/14/11. Review of Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities found that alleged violations of mistreatment, neglect, or abuse under subset 483.13 (c)(2) must initially be reported within twenty-four (24) hours to OHFLAC and to other officials in accordance with State law, and under subset 483.13 (c)(4), the results of the facility's investigation must be reported to OHFLAC and to other officials in accordance with State law within five (5) working days of the incident. During an interview with a social worker (Employee #119) and the director of nursing (DON) on 04/27/11 at 1:25 p.m., neither could find evidence of the immediate or five (5) day reporting to OHFLAC, but they produced a fax cover sheet to OHFLAC dated 03/14/11, the same date the APS report was completed. Also, review of the front of the incident report dated 03/03/11 had a ""checkmark"" noting they intended to send the incident report to OHFLAC. .",2014-08-01
11107,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,250,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to identify medically-related social service needs of the resident, and assure the needs were met by the appropriate disciplines. This was evident for one (1) of six (6) sampled residents who was determined by a physician to lack capacity, but who had no legally-appointed surrogate decision-maker in place. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was determined by his attending physician to possess the capacity to understand and make informed health care decisions, as evidenced by documentation on a physician determination of capacity form dated 12/10/10. Further review revealed Resident #23 was subsequently determined by the facility's medical director to lack this capacity, with the incapacity expected to be of long-term duration related to a [DIAGNOSES REDACTED]. Review of a social service progress note, dated 03/14/11 at 8:30 a.m., by a social worker (Employee #312) found the medical director evaluated Resident #23 for capacity on this date, and the resident grabbed his cane and became agitated and combative with the physician. The social worker and the medical director reviewed paperwork from a previous stay at an inpatient psychiatric facility and confirmed the [DIAGNOSES REDACTED]. -- Review of the attending physician's progress note, dated 03/18/11, revealed the facility's medical director saw Resident #23 and declared him to lack the ability to make health care decisions. However the attending physician ""heard secondhand ... that the patient could not understand (the medical director) too well and got frustrated and somewhat angry and the overall interview did not go too well. This will have to be addressed sometime in (sic) future again I am sure."" He went on to write, ""I think he really does not lack the ability to make certain decisions."" -- Review of a social service progress note, dated 03/25/11 at 11:00 a.m. by Employee #312, revealed the social worker had a conversation with the director of nursing (DON) about Resident #23's capacity. The social worker wrote of plans to call the inpatient psychiatric facility to reschedule his appointment from May 2011 to an earlier date to have them do an ""evaluation and determine capacity as well. However, (name of the facility) stated they don't do that on (sic) out patient basis."" Record review found the cause of the resident's previous incapacity, on 07/02/10 while a patient at an acute care hospital, was due to ""IPH"" (right temporal lobe intraparenchymal hematoma) and ""SDH"" (subdural hematoma). The checklist for surrogate selection was completed at that time, and the daughter was found to be the best qualified to act as a surrogate, noting the wife was ""not appropriate to make decisions at this point"". The resident returned home to live until he was admitted to the nursing facility in December 2010, following a month long inpatient psychiatric stay. -- In an interview on 04/26/11 at 3:30 p.m., Employee #312 she spoke her opinion that, if a person is deemed incapacitated, it needs only one physician to regain capacity status; but to declare non-capacity of a previously capacitated person, it requires two (2) physician statements. Employee #312 further stated, that in July 2010, Resident #23 was determined to be incapacitated / lacking decision making capacity while hospitalized at Ruby Memorial Hospital, and the resident's daughter was appointed the surrogate decision-maker, adding that the spouse was not capable of serving in the role. She further stated that she had spoken with Resident #23's daughter, and the daughter allegedly said she thought hospital form appointing her the surrogate decision-maker was null and void when the resident left the hospital and returned to his home, and the daughter withdrew as the person and deferred to the mother to be the decision-maker. The daughter allegedly said her mother was ""making her life a living hell"" when the daughter tried to make any decisions for the resident. Review of social service progress notes, dated 03/11/11 at 12:15 p.m., attested to the social worker's conversation with the daughter, who said she ""withdrew as person"" because her mother was very angry about the daughter having been selected to make decisions. The daughter allegedly ""expressed concern about her mom and her inability to make good, sound decisions"" and the daughter ""could make them but her mom would 'make life difficult for her'."" When asked if the facility had a policy about capacity or advanced directives, Employee #312 said she did not know of any policy here. -- During an interview with another social worker (Employee #119) on 04/27/11 at 8:30 a.m., she said if a person has capacity, it takes two (2) to say he/she doesn't have capacity, either two (2) physicians, or a physician and a psychiatrist. She said she didn't know how many medical opinions it takes to say a person deemed incapacitated could be deemed to have capacity again. Both she and the DON, when asked, said they weren't sure which of the two (2) differing physician opinions to go with regarding capacity, and they didn't know what they would do if he wanted to home today. When interviewed again on 04/27/11 at 3:30 p.m., Employee #119 said Resident #23 has no medical power of attorney (MPOA) or health care surrogate (HCS) at this point in time. She agreed the medical director assessed him as lacking capacity on 03/14/11, which was the most recent physician determination of capacity form in the resident's record, and said the former social worker (Employee #312), had talked about having the Department of Health and Human Resources (DHHR) be his surrogate, adding there had been some discussions with the wife over the phone but agreeing no decision had been reached yet. Employee #119 also stated she had spoken with the wife over the telephone several times and felt the wife could not comprehend what she was being told. -- During an interview with a licensed practical nurse (LPN - Employee #35) on 04/27/11 at 4:30 p.m., she said the resident's wife was the one who would be notified of any changes, falls, or incidents that occurred with Resident #23, but in her opinion, the wife wasn't any better capacitated than the resident. During an interview with the nurse manager (Employee #165) on 04/27/11 at 4:40 p.m., she said she assumed it would be the wife who would be notified of any changes with the resident if he should fall or have any medical or condition changes. She looked at the resident's chart and said, ""It's usually on the condition alert page who to notify, but there isn't anything there."" During an interview with the DON on 04/27/11 at 4:42 p.m., she said the person to notify was usually put on the condition alert for fast check, but it wasn't there. -- Review of the Health Care Decisions Act related to interinstitutional transfers found at 16-30-13: ""In the event that a person admitted to any health care facility in this state has been determined to lack capacity and that person's medical power of attorney has been declared to be in effect or a surrogate decision maker has been selected for that person all in accordance with the requirements of this article and that person is subsequently transferred from one health care facility to another, the receiving health care facility may rely upon the prior determination of incapacity and the activation of the medical power of attorney or selections of a surrogate decisionmaker as valid and continuing until such time as an attending physician, a qualified physician, a qualified psychologist or advanced nurse practitioner in the receiving facility assesses the person's capacity. Should the reassessment by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner at the receiving facility result in a determination of continued incapacity, the receiving facility may rely upon the medical power of attorney representative or surrogate decisionmaker who provided health care decisions at the transferring facility to continue to make all health care decisions at the receiving facility until such time as the person regains capacity."" .",2014-08-01
11108,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,274,D,1,0,MWLC11,". Based on medical record review, staff interview, and policy review, the facility failed to follow its own policy with implementing a significant change in condition minimum data set (MDS) assessment for one (1) of six (6) sampled residents, when a resident's capacity status had been changed from capacity to incapacity status and was not expected to return. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed the facility's medical director changed Resident #23's capacity status from capacitated to non-capacitated on 03/14/11, citing this incapacity as expected to be of long term duration and related to his dementia. The nature of the incapacitation was evidenced by cognitive loss, disorientation to person, place and time, and the inability to understand or make medical decisions. Review of the most recent MDS for Resident #23, dated 03/10/11, revealed this was an abbreviated quarterly review assessment. During an interview with the director of nursing (DON) on 04/27/11 at 11:45 a.m., she said they did not complete a significant change MDS when this resident's condition changed from capacity to incapacity. She said the quarterly care plan was due at that time, so they completed a quarterly assessment on Resident #23. Review of the facility's policy related to changes in capacity / incapacity (revised September 2008) revealed, under section D,: ""MDS Coordinator will be notified by nursing immediately by phone. Nursing will prepare information to present at the next weekly Resident Review Meeting. The team will then implement a Significant Change in Condition MDS if incapacity is not expected to change."" .",2014-08-01
11109,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,280,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plan for one (1) of six (6) sampled residents when the resident exhibited a change in capacity status and a significant change in emotional status with identifiable triggers, which were not included on the plan of care. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was determined by his attending physician to possess the capacity to understand and make informed health care decisions, as evidenced by documentation on a physician determination of capacity form dated 12/10/10. Further review revealed Resident #23 was subsequently determined by the facility's medical director to lack this capacity, with the incapacity expected to be of long-term duration related to a [DIAGNOSES REDACTED]. Review of the current care plan, with initiation date of 03/10/11, found no mention of his status having changed to incapacity, nor of who was to serve as his surrogate decision-making (and was to be notified in the event of physical, mental, or emotional condition changes, or medication or treatment changes). Review of Resident #23's medical record revealed ongoing domestic issues within the family, and the spouse was known by the facility to trigger an escalation in the resident's agitation. However, review of the current care plan found it did not address the spouse as a trigger for his behaviors and agitation, nor were any plans developed to circumvent future instances of this nature. Review a psychiatric admission history and physical (H&P) dated 11/01/10 revealed this resident was admitted to an acute care hospital on [DATE] and discharged on [DATE], with the resident exhibiting mild dementia at his baseline prior to the discovery of a subdural hematoma. The resident had, reportedly, been hit in the head by a family member ten (10) days prior to sustaining a fall and hematoma. While in a step-down unit, the ""patient was noted to be agitated with problems of impulsivity that required restraints multiple times."" Further review of the H&P dated 11/01/10 revealed this resident initially transferred into the psychiatric unit after being admitted through the emergency department due to domestic violence (.i.e., ""he was hitting his wife and his son had to protect his mother""). The resident stayed at the acute care hospital for five (5) days before being transferred to an inpatient psychiatric facility due to continuing agitation, aggression, and confusion. Record review of neuropsychological testing completed 12/01/10 found: ""Records indicate that he has significant functional decline, and his relationship with his wife is extremely impaired."" Furthermore, ""Keeping an eye on him for safety will be increasingly important given the severity of his memory problems. He will require extensive supervision during most activities. Records indicate that he is also presenting with significant behavioral and emotional problem which will require ongoing management."" Review of social service progress notes, dated 03/03/11 beginning at 3:00 p.m., revealed the wife visited the resident, then entered the social worker's office and stated, ""You can't let him leave out that door."" Early during this incident of resident agitation and attempting to leave the facility, Employee #312 tried to separate the wife and the resident and encouraged the wife to leave at that time due to the resident being angry, but she refused. Finally, she did leave. This episode of increased agitation lasted approximately an hour and involved police intervention. Review of nursing notes, dated 03/04/11, 03/08/11, and 03/09/11, revealed the resident's wife called and spoke with nurses of her concern that the resident might come home, once stating, ""You just don't understand what I went through."" Review of a physician's progress note dated 03/18/11 found he ""got the overall idea that his wife, if anything, was agitating him more than she was trying to help"", related to the incident which occurred 03/03/11 when the wife visited. During an interview with a social worker (Employee #312) on 04/26/11 at 3:30 p.m., she stated Resident #23 had confusion at times but can always be redirected, and he had never been aggressive before the incident on 03/03/11. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 previously lived at home but allegedly attacked his wife, who called the police and an ambulance. He was taken to the emergency department and, from there, to an inpatient psychiatric hospital in November 2010. She said the wife had not been to the facility before or after the 03/03/11 incident, at which time she visited and the resident became extremely agitated. However, the wife sometimes calls and to speaks with him, and after he talks with her, he acts ""kind of agitated"". She added that the wife ""doesn't seem to comprehend what you're saying"". During an interview with the director of nursing (DON) on 04/27/11 at 11:45 a.m., she said they did not care plan specific interventions about behavioral triggers (such as the wife) and said, possibly, they should have done more specific care planning in that area, as the wife allegedly will also cause him to become agitated with telephone calls. The DON agreed they did not have a written plan in place for if or when the wife would show up again at the facility. During an interview with a licensed practical nurse (Employee #35) on 04/27/11 at 4:30 p.m., she said the wife allegedly had a court order against the resident. She stated there was currently no plan in place if the wife should return to the facility; rather, they will just have to react to whatever circumstances happen.",2014-08-01
11110,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-04-21,166,D,1,0,SI9V11,". Based on interview with interviews with residents, staff, and visitors and record review, the facility failed to make prompt efforts to resolve grievances reported by residents with respect to the disruptive behaviors of their roommates. This was evident for three (3) of eleven (11) sampled residents, whose roommates were identified as having problem behaviors. Resident identifiers: #19, #37, and #46. Facility census: 96. Findings include: a) Residents #19, #37, and #46 1. Resident #19 When interviewed on the afternoon of 04/21/11, Resident #19 reported that her roommate (#39) exhibited behaviors that were disturbing to her, such as yelling out for family members or that she wishes to go home. When asked how staff addressed her roommate's yelling, Resident #19 reported that staff will come in and tell her she has to stay there and try to talk to her. 2. Resident #37 According to a visitor who wished to remain anonymous, when interviewed on the afternoon of 04/21/11, Resident #37 rarely spoke to others but she had, at times, spoken out to say she wished her roommate (Resident #13) would ""shut up"". According to the visitor, Resident #13 yells and makes noise that is disturbing to Resident #37. It was revealed, through other confidential sources, this issue had been brought to the attention of the staff but nothing had been done about it. Review of the facility's internal complaint records found no indication that Resident #37's concern with her roommate's behavior had been documented and addressed by administrative staff. 3. Resident #46 Resident #46 also shared a room with Resident #13. When asked if she had any concerns with her roommates, during an interview on the afternoon of 04/21/11, Resident #46 reported she found Resident #13's behavior to be disturbing. She said Resident #13 yells and makes noises most of the time. -- b) Review of the facility's complaint records for Residents #19, #37, and #46 found no mention of these residents having expressed concerns with the disruptive behaviors of their roommates. -- c) Interview with the administrator (Employee #2), social worker, (Employee #109), and admissions coordinator (Employee #110), on the afternoon of 04/21/11, revealed there was no documentation available regarding how the facility was addressing the residents' concerns about the disruptive behaviors of their roommates.",2014-08-01
11111,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,441,F,1,0,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to: ensure employees donned appropriate personal protective equipment (PPE) prior to entering the rooms of residents who were to be cared for using physician-ordered transmission-based precautions; ensure staff washed their hands after direct contact with infected residents and/or contaminated environmental surfaces in the residents' rooms when isolation precautions were to have been used; and appropriately cohort residents when isolation precautions were in use. Additionally, a nursing assistant filled water pitchers with ice in a manner that could potentially contaminate the ice chest used to distribute ice to all residents on 100 Hall, and ten (10) residents of random opportunity were observed to be seated in the dining room and served their meals without receiving assistance from staff with hand hygiene. These practices affected five (5) of eight (8) residents in isolation, one (1) resident who was not improperly cohorted with a resident in isolation, all residents on 100 Hall, ten (10) residents of random opportunity during the evening meal service on 04/04/11, and had the potential to affect all residents in the facility. Resident identifiers: #136, #81, #53, #94, #92, and #133. Facility census: 115. Findings include: a) Residents #136 and #81 Observation, on 04/04/11 at 5:50 p.m., found an employee entering the room shared by Residents #136 and #81 carrying a meal tray. A sign posted on the door to this room announced contact precautions were to be used and visitors were to see the nurse before entering. The employee did not don any PPE before entering the room. The employee delivered the meal tray to the resident and assisted the resident with setting up the meal tray. The employee touched multiple surfaces while in the room, including the resident's bed and bedside table. The employee did not wash her hands after exiting the room and continued passing meal trays to other residents on the hall. Review of Resident #136's physician orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 04/04/11 at 6:20 p.m., an interview with the director of nursing (DON - Employee #82) revealed residents with a positive RSV culture should be placed on droplet precautions. On 04/04/11 at 6:40 p.m., an interview with a licensed practical nurse (LPN - Employee #44) revealed Residents #136 and #81 were only on contact precautions; she made no mention of the droplet precautions. Review of information published by the Centers for Disease Control and Prevention (CDC) regarding transmission prevention of RSV revealed that infection can be spread as a result of direct and indirect contact with nasal or oral secretions. Indirect contact can occur if the virus gets on environmental surfaces that are then touched by other people. There were discrepancies between staff members regarding what level of transmission-based precautions should have been in use when caring for Residents #136 and #81, who were both positive for RSV. Contact precautions would have been sufficient to prevent the transmission of RSV to other residents, although the physician ordered droplet precautions. In either case, however, an unidentified employee, who was observed to have entered the room shared by these residents on the evening of 04/04/11, did not don the appropriate PPE prior to entering the isolation room, nor did that employee perform hand hygiene prior to exiting that room and after having direct contact with contaminated environmental surfaces. -- b) Resident #53 An observation, on 04/13/11 at 12:05 p.m., found Resident #53 occupied a private room with signage indicating contact precautions were to be used. At 12:10 p.m. on 04/13/11, a nursing assistant (Employee #31) entered Resident #53's room to deliver a meal tray and failed to don appropriate PPE before entering the room. On 04/13/11 at 12:15 p.m., an interview with the assistant director of nursing (ADON - Employee #96) revealed the infectious organism was present in the resident's urine and that all staff should be wearing a gown and gloves. On 04/13/11 at 12:40 p.m., an interview with the infection control nurse (Employee #66) revealed staff should wear all PPE at all times when entering Resident #53's room. Medical record review revealed Resident #53 was positive for [DIAGNOSES REDACTED] pneumoniae in her urine. -- c) Resident #94 Review of Resident #94's nursing notes revealed the resident was placed on contact isolation precautions on 03/31/11, due to [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in his urine. On 04/06/11 at 3:20 p.m., an employee from the therapy department was observed exiting Resident #94's room. Upon exiting the room, the employee removed her gloves but did not wash her hands. When interviewed at that time, the therapy employee confirmed she did not wash her hands before exiting Resident #94's room, but she did wash them after arrived at and entered the therapy department. -- d) Resident #92 Review of Resident #92's medical record revealed a final lab report, dated 04/03/11, stating the resident's urine cultured positive for [DIAGNOSES REDACTED] pneumoniae Carbapenemase (KPC). Further review of Resident #92's medical record revealed the following physician's orders [REDACTED]."" Resident #92 also had an indwelling Foley urinary catheter in place. On 04/13/11 at 2:19 p.m., an LPN (Employee #77) entered Resident #92's room without donning any PPE. Employee #77 proceeded to administer the resident's medication and was noted to touch multiple surfaces in the resident's room. Employee #77 then exited the room without washing her hands and continued passing medications to other residents. Further observation noted the resident's catheter was pulled out; urine had leaked onto the resident's bed, and the resident's husband was cleaning the resident. NOTE: On 04/13/11 at 3:05 p.m., an interview with the resident's husband revealed he had been made aware of ""the bug"" that his wife had in her urine and that he had worn gloves while providing care to his wife earlier that day. -- e) Resident #133 Review of Resident #94's physician orders [REDACTED].#133 on 02/22/11. Resident #94's nursing notes revealed he was placed on contact isolation precautions due to VRE in his urine on 03/31/11. Resident #94's physician orders [REDACTED]. Review of Resident #133's nursing notes revealed this resident had sustained a fall and received an abrasion to his left knee on 03/22/11. On 04/06/11 at 11:55 a.m., an interview with Employee #66 revealed Resident #94 was moved ""because we realized that his roommate had a skin tear. "" On 04/06/11 at 2:20 p.m., an interview with the DON confirmed Resident #94 was moved on 04/05/11 due to his roommate having a skin tear. She further stated Resident #94 should have been moved at the time Resident #133 sustained the skin tear (which was on 03/22/11). -- f) During random observations of the resident environment on 04/05/11 at 9:55 a.m., a nursing assistant (Employee #30) was observed while passing ice on the 100 hallway. Employee #30 entered multiple resident rooms, exited the rooms with water pitchers, and held the pitchers over the ice chest while using a scoop to fill them. This practice allowed any contaminates present on the outside of the pitchers to fall into the ice and be passed to other residents. -- g) During random observations of the evening meal on 04/04/11 at 4:49 p.m., staff was observed to bring residents to the dining room and seat them at tables. Ten (10) residents of random opportunity were seated in the dining room when the meal was served. Staff did not assist residents to cleanse their hands prior to the meal. An interview with a nursing assistant (Employee #62), at 5:25 p.m. on 04/04/11, elicited the residents were usually assisted with cleaning their hands using moist towelettes, but they had forgotten to do that prior to this meal.",2014-08-01
11112,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,157,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to notify the legal representative of one (1) of three (3) sampled residents when she had been restrained to her bed without a physician's order. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found that, on 03/10/11 at approximately 9:00 p.m., a quality assistant (QA - Employee #0) reported Resident #65's was restrained in her bed by a tightly tucked blanket / sheet. Review of Resident #65's medical record found no physician's order or care plan for the resident to be restrained in her bed by the use of tightly tucked sheets or blankets. Review of the facility's interview investigation, and interviews with facility staff and former staff conducted on 03/30/11, 03/31/11, and 04/01/11, confirmed the blanket / sheet on Resident #65's bed had been tightly tucked beneath her bed to the point that staff had to tear the blanket / sheet in order to free the resident. An interview with the director of nursing (DON), on the afternoon of 03/31/11, elicited that Resident #65's legal representative was not contacted about the incident nor informed that the resident had been restrained without a physician's order, until he came into the facility on [DATE]. The DON stated the legal representative relayed that a woman had called him and told him Resident #65 had been found tied to her bed. .",2014-08-01
11113,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,221,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out ""Baby Doll"". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body but could only lift up about a foot. When she looked closer, she saw the resident's sheet and blanket was ""really tight"" across her abdomen. She reported this to Employee #65, a medical records clerk. 2. Employee #65 (medical records clerk) Employee #65 was interviewed at 3:19 p.m. on 03/30/11. She stated she worked late on the evening of 03/10/11 when, at about 9:30 p.m., Employee #0 approached her and told her she needed to check Resident #65, as the QA believed the resident was being restrained. Employee #65 went into Resident #65's room and noticed the resident was lying on her back on the bed. Employee #65 described walking over to the resident's bed and pulling on the blanket beneath her breast area, which appeared to be tight. She stated she was only able to move the blanket about an inch from the resident's body. She stated she reported the resident's condition to the charge nurse, a licensed practical nurse (LPN - Employee #93). 3. Employee #93 (an LPN) Employee #93 was interviewed at 8:45 a.m. on 03/31/11. She stated that, at approximately 9:15 p.m., Employee #65 requested her to come and look at Resident #65, that she was tied to her bed. Employee #93 described that, when she entered the resident's room, she noted a thin white blanket was tucked tightly under the resident's mattress. She left the room to get assistance from Employee #22, a certified nursing assistant (CNA). She stated both she and Employee #22 had to rip the blanket to get it off the resident. 4. Employee #4 (a QA) Employee #4 was interviewed at 4:43 p.m. on 03/30/11. She stated that, two or three days before 03/10/11, she and another QA were in Resident #65's room with a CNA (Employee #25). She stated Employee #25 showed them that the resident's sheet was tucked between the mattress and the bed frame. She relayed that Employee #25 stated, ""This is why (Resident #65) isn't getting up."" Employee #4 stated the QAs were required to watch Resident #65, because she would try to stand up / get up when she is in her bed and would fall. She stated it was really hard to pass ice and snacks and also have to watch this resident. 5. Employee #47 (the social worker) Employee #47, the social worker for the facility, was interviewed on the afternoon of 03/31/11. She stated she saw the blanket that had been removed from Resident #65's bed. She described two (2) jagged tears on two (2) of the corners of the resident's blanket. 6. Employee #25 (a CNA) Employee #25 was the CNA assigned to care for Resident #65 on the evening shift on 03/30/11. He was the only aide assigned to the resident's hallway. He was interviewed at 5:04 p.m. on 03/31/11. He denied restraining the resident by tightly tucking the blanket or sheet under the resident's mattress. 7. Employee #68 (a CNA) An interview with Employee #68 was conducted at 6:54 p.m. on 03/30/11. She stated that, on the evening shift on 03/30/11 after the 9:00 p.m. bedcheck, Employee #22 told them they were not to ""tie nobody up, restrain nobody, tie the covers or tuck them in until they can't move"". When Employee #68 asked Employee #22 why they were being told this, she stated Employee #22 informed her they had to rip the two (2) corners of the sheets to get Resident #65's covers loose. -- The facility obtained a statement from Employee #22, a CNA who worked night shift aide on 03/11/11. Her statement concurred that Resident #65's sheet was tucked tightly under the mattress. (This individual was not available to be interviewed by the surveyor.) -- Review of the State Operations Manual, Guidance to Surveyors, F221, found examples of restraints included, ""... Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted..."". .",2014-08-01
11114,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,225,D,1,0,0DKH11,". Based on staff interview, review of the facility's abuse / neglect policies, and review of facility documents, the facility failed to ensure all allegations of abuse / neglect were immediately reported in accordance with State law for one (1) of two (2) allegations. Additionally, the facility failed to conduct a thorough investigation into this allegation, which was that a certified nursing assistant (CNA) was giving residents oral medications and an insulin injection. Facility census: 84. Findings include: a) During an interview conducted with a quality aide (QA - Employee #0) on the morning of 03/30/11, she stated she had reported to a licensed practical nurse (LPN - Employee #83) that a CNA (Employee #64) was witnessed giving oral medications and an insulin shot around the first part of February 2011. Review of the facility's reportable files for the previous three (3) months found no evidence the LPN reported this allegation as required. Review of the facility's abuse and neglect policies found the following: ""THE INDIVIDUAL WHO OBSERVES AN INCIDENT OF ABUSE OR NEGLECT MUST BE THE ONE WHO REPORTS IT. THIS MUST BE REPORTED IMMEDIATELY TO THE LOCAL DEPARTMENT OF HUMAN SERVICES, ADULT PROTECTIVE SERVICE DIVISION..."". When interviewed on the afternoon of 03/31/11, Employee #83 confirmed Employee #0 had reported this alleged abuse / neglect to her. She stated she did not report the allegation, and she could provide no evidence that a thorough investigation had been conducted.",2014-08-01
11115,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,279,E,0,1,6TSD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to initiate a care plan and/or adequately address problems identified in the comprehensive resident assessment for five (5) of thirteen (13) sampled residents. Resident identifiers: #83, #78, #24, #43, and #158. Facility census: 101. Findings include: a) Resident #83 A review of Resident #83's medical revealed an [AGE] year old female with [DIAGNOSES REDACTED]. She was identified, on her quarterly minimum data set assessment (MDS) completed on 04/08/09, as exhibiting the behavior of wandering, and there were two (2) recorded incidents of resident-to-resident conflicts (08/01/08 and 03/06/09) involving her wandering behavior. A resident assessment protocol indicated this behavior would be care planned, but a review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the director of nursing (DON) at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, ""Resident @ risk for injury R/T (related to) wandering with-in facility."" b) Resident #78 A review of Resident #78's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At the confidential resident group meeting held at 3:00 p.m. on 04/28/09, five (5) residents in attendance complained about Resident #78 wandering in and out of their rooms many times during the night. Resident #78 was also observed walking in a random manner several times throughout the survey. Review of her significant change in status MDS (02/07/08) and the most recent quarterly MDS (03/04/09) revealed the assessor indicated the resident exhibiting wandering during the assessment reference periods, and a resident assessment protocol (RAP) completed in conjunction with the significant change in status MDS indicated this behavior would be addressed in the resident's care plan. A review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the DON at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, ""Resident @ risk for injury R/T wandering with-in facility."" c) Resident #24 A review of Resident #24's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. At the confidential resident group meeting held at 3:00 p.m. on 04/28/09, five (5) residents in attendance complained about Resident #24 wandering in and out of their rooms many times during the night. Nurses notes documented the following: - On 02/19/09, ""... up all night. Physically combative when redirected."" - On 03/06/09, ""... up ambulating all hours day and night. Only sleeps short periods."" - On 04/27/09, ""Wandered throughout night."" The quarterly MDS (03/25/09) identified the resident as exhibiting wandering behaviors which are not easily redirected, and there was an incident report regarding elopement, when he exited the building on 04/27/09. A review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the DON at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, ""Resident @ risk for injury R/T wandering with-infacility."" d) Resident #43 Review of Resident #43's current care plan, on 04/27/09, revealed the facility had not addressed wandering as a care problem for this resident. Observations of Resident #43, on 04/28/09 and 04/29/09, revealed the resident would wander into the rooms of other residents. Observation, on 04/29/09 at 2:20 p.m., found Resident #43 in the hallway her scooter chair removing the soft Velcro bars from the door frame of another's resident room and entering hallway into the room. Interview with the resident occupying the room into which Resident #43 entered revealed this occurred frequently. In an interview on the late afternoon of 04/29/09, Employee #80 acknowledged Resident #43 did wander into other residents' room. e) Resident #158 A review of nursing notes found an entry, dated 01/22/09, recording the resident was found in a male resident's room, sitting on the male resident's bed. The male resident had his hand on Resident #158's thigh, and staff believed the male resident through Resident #158 was his wife. A subsequent nursing note, later on 01/22/09, indicated Resident #158 was still wandering into other residents' rooms. A review of the nurse's notes found the resident was put on one-on-one monitoring, and a care plan was developed on 01/27/09, which was later discontinued on 01/30/09. On 01/30/09, the resident's care plan was updated to indicate staff was to monitor the resident every fifteen (15) minutes; this intervention was discontinued on 02/03/09. Further record review revealed a nursing note, dated 02/11/09 at 11:35 a.m., recording this resident drank approximately 1 teaspoon of green apple hand sanitizer. A review of the incident report and accompanying investigation found the resident accessed the hand sanitizer in the housekeeping supervisor's office. A review of the 02/11/09 interim care plan found the resident was to be in areas of supervision. On 02/22/09, the resident continued to wander in and out of other residents' rooms and was hard to redirect. The resident described was ""combative and unwilling to leave other's rooms."" Nursing notes, dated 03/06/09, 03/08/09, 03/22/09, and 03/26/09, contained descriptions of wandering, difficulty redirecting, rummaging in other residents' closets, drinking other residents' drinks, and waking up other residents. On 04/11/09, the resident's care plan was revised in response to Resident #158 striking out at another resident. Interventions included: ""redirect, remind of inappropriate behavior and not to strike, and monitor activity..."" On 04/12/09, the resident was found outside. The care plan included interventions, such as: ""Maintain Watchmate sensor per orders, monitor whereabouts through shifts, and answer alarms promptly."" The care plan did not include interventions developed specifically for the resident. A review of the resident's entire current care plan found a care plan had not been developed to address the identification what might be precipitating the resident's behaviors. Interventions in the care plans only addressed interim and temporary solutions but did not address ongoing and specific interventions for the resident. . d) Resident #43 Review of Resident #43's current care plan, on 04/27/09, revealed the facility had not addressed wandering as a care problem for this resident. Observations of Resident #43, on 04/28/09 and 04/29/09, revealed the resident would wander into the rooms of other residents. Observation, on 04/29/09 at 2:20 p.m., found Resident #43 in the hallway her scooter chair removing the soft Velcro bars from the door frame of another's resident room and entering hallway into the room. Interview with the resident occupying the room into which Resident #43 entered revealed this occurred frequently. In an interview on the late afternoon of 04/29/09, Employee #80 acknowledged Resident #43 did wander into other residents' room. e) Resident #158 A review of nursing notes found an entry, dated 01/22/09, recording the resident was found in a male resident's room, sitting on the male resident's bed. The male resident had his hand on Resident #158's thigh, and staff believed the male resident through Resident #158 was his wife. A subsequent nursing note, later on 01/22/09, indicated Resident #158 was still wandering into other residents' rooms. A review of the nurse's notes found the resident was put on one-on-one monitoring, and a care plan was developed on 01/27/09, which was later discontinued on 01/30/09. On 01/30/09, the resident's care plan was updated to indicate staff was to monitor the resident every fifteen (15) minutes; this intervention was discontinued on 02/03/09. Further record review revealed a nursing note, dated 02/11/09 at 11:35 a.m., recording the this resident drank approximately 1 teaspoon of green apple hand sanitizer. A review of the incident report and accompanying investigation found the resident accessed the hand sanitizer in the housekeeping supervisor's office. A review of the 02/11/09 interim care plan found the resident was to be in areas of supervision. On 02/22/09, the resident continued to wander in and out of other residents' rooms and was hard to redirect. The resident described was ""combative and unwilling to leave other's rooms."" Nursing notes, dated 03/06/09, 03/08/09, 03/22/09, and 03/26/09, contained descriptions of wandering, difficulty redirecting, rummaging in other residents' closets, drinking other residents' drinks, and waking up other residents. On 04/11/09, the resident's care plan was revised in response to Resident #158 striking out at another resident. Interventions included: ""redirect, remind of inappropriate behavior and not to strike, and monitor activity..."" On 04/12/09, the resident was found outside. The care plan included interventions, such as: ""Maintain Watchmate sensor per orders, monitor whereabouts through shifts, and answer alarms promptly."" The care plan did not include interventions developed specifically for the resident. A review of the resident's entire current care plan found a care plan had not been developed to address the identification what might be precipitating the resident's behaviors. Interventions in the care plans only addressed interim and temporary solutions but did not address ongoing and specific interventions for the resident. .",2014-08-01
11116,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,152,D,0,1,6TSD11,"Based on record review and staff interview, the facility failed to ensure that the persons making healthcare decisions for two (2) of thirteen (13) sampled residents, who had been determined to lack the capacity to make such decisions for themselves, were appointed in accordance with State law. Resident identifiers: #45 and #60. Facility census: 101. Findings include: a) Resident #45 A review of Resident #45's medical record revealed a copy of a document appointing the resident's son as her medical power of attorney representative (MPOA). Review of the resident's advance directives, consents for vaccination, and other legal documents revealed these healthcare decisions had been made by the resident's daughter as evidenced by her signatures on these documents. During an interview with the director of nursing (DON) at 5:15 p.m. on 04/28/09, she stated the son was the MPOA of record, but the facility accepted the daughter's signature because she was the one who came in most often. b) Resident #60 A review of Resident #60's medical recordrevealed the individual who gave consent for a do not resuscitate order and for use of psychoactive medications, and who made other healthcare decisions for Resident #60 was not the person designated by the resident to serve as MPOA. During an interview with the DON at 5:15 p.m. on 04/28/09, she acknowledged that the person making the resident's healthcare decisions was not the resident's legally appointed MPOA.",2014-08-01
11117,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,150,D,0,1,6TSD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon a resident's wish to change her advance directives. Resident #54, who was determined to possess the capacity to understand and make her own medical decisions, upon admission indicated she wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or [MEDICAL CONDITION] arrest. Shortly after admission, she decided she did not want to receive CPR, and the facility failed to act upon her request for do not resuscitate (DNR). Resident identifier: #54. Facility census: 101. Findings include: a) Resident #54 Record review, on [DATE], revealed Resident #54 was admitted to the facility on [DATE]. Review of her interdisciplinary progress notes (by nursing) revealed an entry, dated [DATE], stating the resident was a ""full code at this time"", meaning the resident was to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest. A physician's orders [REDACTED]. Review of a subsequent entry in the interdisciplinary progress notes (by social services), dated [DATE], revealed, ""POST (physician's orders [REDACTED]. Code status DNR."" This form was completed by the resident and Employee #133, but there was no physician's signature on it. Interview with Employee #80 on [DATE], and with other staff reviewing the resident's medical record on [DATE], confirmed the facility had not followed through to ensure the resident's request for DNR was confirmed by an order signed by the attending physician. .",2014-08-01
11118,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,156,E,0,1,6TSD11,"Based on record review and staff interview, this Medicare-participating facility failed, for four (4) of four (4) residents reviewed, for whom a determination was made by the facility that Medicare will not pay for skilled nursing or specialized rehabilitative services and that an otherwise covered item or service may be denied as not reasonable and necessary, to notify the resident or his/her legal representative in writing why these specific services may not be covered; the beneficiary ' s potential liability for payment for the non-covered services; the beneficiary right to have a claim submitted to Medicare; and the beneficiary ' s standard claim appeal rights that apply if the claim is denied by Medicare. This practice had the potential to affect all residents for whom a determination of non-coverage by Medicare had been made by the facility. Resident identifiers: #52, #99, #66, and #4. Facility census: 101. Findings include: a) Residents #52, #99, and #66 A review of the forms entitled ""SNF Determination on Continued Stay"" for these residents revealed only the date that Medicare-covered services would be discontinued; there was no mention in writing of what specific service may no longer be covered or why. The only verbiage included in the form was ""no longer requires skilled services"" or ""exhausted benefits"". During an interview with the administrator and the office person responsible for providing this notification at 3:20 p.m. on 04/27/09, they acknowledged that this was form given to the resident and/or the responsible party as the notification of discontinuance of Medicare-covered skilled services and of their right to appeal this decision. They also agreed, after reviewing the forms, that the documentation did not on these residents' forms did not specify the service that was no longer being covered. When asked, neither person was able to state, during the interview, exactly what service had been discontinued for each of these three (3) residents. b) Resident #4 A review of the Notice of Medicare Provider Non-coverage notice provided to Resident #4 and/or her responsible party revealed: ""Resident will no longer receive speech therapy effective 4/26/09."" However, this notice did not include any reason for why the service was being discontinued. During an interview with the administrator and the office person responsible for notification at 3:20 p.m. on 04/27/09, they acknowledged that this was the only documentation given to the resident. c) In the interview of 04/27/09, the person responsible for obtaining signatures on the non-coverage notification forms stated she assumed that someone else had explained the service involved and why it was being stopped prior to the notification being signed, but both she and the administrator acknowledged, after reviewing the above residents' forms, that the Medicare-covered skilled services being discontinued and/or the reasons for discontinuation were not there. .",2014-08-01
11119,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2011-04-19,492,C,1,0,X5LS11,". Based on review of sampled employee files and staff interview, the facility failed to provide to each nurse aide in its employ a copy of WV Legislative Rule 69-6 (Nurse Aide Abuse Registry rule) as required by Section 8 of that law. This was evident in four (4) of eight (8) employee files reviewed. Employee identifiers: #70, #75, #76, and #77. Facility census: 65. Findings include: a) Employees #70, #75, #76, and #77 According to ?69-6-8. Facility Notice and Record Keeping: ""8.1. Facilities shall provide a copy of this rule to each Nurse Aide on their staff and to each Nurse Aide at the time of hiring and keep signed proof that each Nurse Aide has received a copy of the rule."" When reviewed on the morning of 04/19/11, the personnel files of four (4) of eight (8) sampled nurse aides (#70, #75, #76, and #77) did not contain evidence that copies of the Nurse Aide Abuse Registry rule as required by that law: - Employee #70 (hired 10/18/10), - Employee #75 (hired 12/23/10), - Employee #76 (hired 12/23/10), and - Employee #77 (hired 01/11/11). Other sampled employees (#16, #29, #52, and #55) did have a signed form in their personnel file stating they acknowledged receiving a copy of Nurse Aide Abuse Registry rule. These were nurse aides who had been employed by the facility prior to July 2010. Discussion with the staff development coordinator (Employee #64), at 12:10 p.m. on 04/19/11, revealed she was the individual responsible for completing new employee orientation. She stated she had not been giving that documentation since she began working in that position in August 2010. This was also discussed with the administrator (Employee #62) at 12:30 p.m. on 04/19/11. She verified the information had not been given to nurse aides as required.",2014-08-01
11120,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2009-05-08,323,E,0,1,V73M11,"Based on observation and staff interview, the facility failed to ensure the environment was as free of accident hazards as possible. During the medication pass observation, one (1) of four (4) nurses observed failed to ensure filled syringes and medications were locked in the medication cart when the cart was left unattended and out of the nurse's line of sight. Facility census: 27. Findings include: a) During the medication pass on 05/06/09 at 9:05 a.m., when approaching the medication cart on the 260 hall, observation found the cart was unattended in the hall. Further observation found two (2) 10 cc syringes containing a clear liquid and two (2) 50 cc bags which contained IV (intravenous) medications on top of the cart. Observation of the 260 hall found the medication nurse (Employee #29) was in a resident's room and not within sight of the medication cart. During an interview on 05/06/09 at 10:30 a.m., the director of nursing confirmed that the practice of leaving filled syringes and medications unattended on top of a medication cart presented an accident hazard and the medications should have been locked in the cart. .",2014-08-01
11121,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2009-05-08,431,E,0,1,V73M11,"Based on observation and staff interview, the facility failed to ensure drugs used in the facility were stored under proper temperature controls. Observation of one (1) of one (1) refrigerator in the facility, used to store drugs requiring refrigeration, found the internal temperature was 50 degrees Fahrenheit (F). The refrigerator contained three (3) vials of Novolin R insulin, two (2) boxes containing vials of influenza virus vaccine, and one (1) 50 cc bag of IV (intravenous) Vancomycin which required refrigeration. Both the insulin and the influenza vaccines are to be stored in a refrigerator with an internal temperature between 36 degrees F and 46 degrees F. This practice had the potential to alter the effectiveness of temperature-sensitive drugs. Facility census: 27. Findings include: a) Inspection of the refrigerator in the medication room, on 05/06/09 at 9:45 a.m., found the thermometer inside the refrigerator indicated an internal temperature reading of 50 degrees F. Review of May 2009 temperature log for this refrigerator revealed temperatures of 50 degrees F on the 05/01/09, 05/03/09, and 05/05/09. The temperature log for April 2009 recorded readings of 50 degrees F on 04/23/09 and 48 degrees F on 04/24/09 and 04/26/09. The temperature log for March 2009 recorded temperatures of 48 degrees F on 03/04/09 and 03/06/09, with a high reading of 60 degrees F on 03/08/09. Inspection of the contents of the refrigerator revealed three (3) vials of Novolin R insulin, two (2) boxes containing vials of influenza vaccine, and one (1) 50 cc bag of IV Vancomycin which had been mixed. According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition), unopened vials of Novolin R insulin are to be stored in a refrigerator with an internal temperature between 36 degrees F and 46 degrees F. Review of the instructions on one (1) of the boxes of influenza vaccine revealed this, too, was to be kept refrigerated between 36 degrees F and 46 degrees F. During an interview on the morning of 05/06/09, the facility's pharmacist confirmed the temperature of the refrigerator was too high for the proper storage of temperature-sensitive drugs, and this should have been reported. .",2014-08-01
11122,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2009-05-08,225,D,0,1,V73M11,"Based on a review of facility complaint records and staff interview, the facility failed to implement its policy regarding the reporting of neglect for one (1) of three complaints reviewed. Complaint #l included allegations of a nursing assistant refusing to assist a resident to find her shoes and refusing to bath the resident. There was no evidence to reflect this allegation of neglect had been reported to State agencies, including the Nurse Aide Abuse Registry, as required by State law. Facility census: 27. Findings include: a) Complaint #1 Review of the facility's complaint records revealed Complaint #1, dated 12/11/08, which documented a resident's report that a nursing assistant had refused to help find her shoes and refused to give her a bath because she was going home. Further review revealed no evidence the facility reported this allegation of neglect to State agencies, including the Nurse Aide Abuse Registry, as required by State law and in accordance with the facility's abuse policy (which was reviewed on 05/07/09). During an interview on 05/07/09 at 1:30 p.m., the director of nursing (Employee # 49) confirmed this allegation of neglect had not been reported to State agencies as required. .",2014-08-01
11123,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,157,E,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, family interview, and staff interview the facility failed to notify the physician of a need to discontinue isolation precautions when two (2) of five (5) sampled residents in isolation had negative lab results and/or absence of symptoms of infection, and failed to notify the physician and/or family when one (1) of nine (9) sampled residents did not have an indwelling suprapubic urinary catheter changed monthly as ordered and was exhibiting symptoms of a urinary tract infection. Resident identifiers: #105, #103, and #68. Facility census: 111. Findings include: a) Resident #105 During the general tour at 10:30 a.m. on 04/11/11, observation found Resident #105 sitting in a chair in his room on the South unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #79) confirmed Resident #105 was in isolation. A review of the treatment book revealed Resident #105 was in contact isolation since 12/14/10 for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #105's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Neither the hospital discharge summary dated 10/18/10, nor the facility's history and physical dated 10/22/10, provided documentation that [MEDICAL CONDITION] infection had been present at the time of his admission, and a urine culture completed on 11/19/10 was negative [MEDICAL CONDITION]. The resident was ordered Bactrim on 12/09/10, and a urine specimen for culture and sensitivity (C&S) was sent to the laboratory. The urine culture was reported as positive [MEDICAL CONDITION] on 12/13/10, and the physician ordered ""Contact Isolation [MEDICAL CONDITION] in urine"" on 12/14/10. The lab report revealed Bactrim was an appropriate treatment for [REDACTED]. A urine culture completed on 12/23/10 was negative for growth. During an interview with the director of care delivery (DCD) for the South unit (Employee #67) at 3:10 p.m. on 04/11/11, she stated, after reviewing the resident's medical record, that she could find no reason for the isolation precautions to remain in place. An observation, at 1:20 p.m. on 4/12/11, revealed Resident #105's room was still posted with a contact isolation sign. A review of the resident's comprehensive assessments, at 2:45 p.m. on 04/12/11, with the assistance of the assessment coordinator (Employee #168), revealed Resident #105's abbreviated quarterly assessment dated [DATE] contained no evidence of either a urinary tract infection or the presence of a multi-drug resistant organism (MDRO), such [MEDICAL CONDITION]. During an interview with the director of nursing (DON - Employee #166) at 9:30 a.m. on 04/13/11, she acknowledged Resident #105 was in isolation, but she expressed surprise that it had been in effect for so long and stated she would follow up on it. The DON (who was the facility's infection control coordinator) also acknowledged that Resident #105 had not been listed on any of the 2011 monthly surveillance reports due [MEDICAL CONDITION]. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #67, and the DCD for the North unit (Employee #20) at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #105's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. -- b) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 [MEDICAL CONDITION] in urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a urinary tract infection [MEDICAL CONDITION] on 11/10/10, and contact isolation due [MEDICAL CONDITION] on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. Further review of the medical record revealed a urine culture completed on 01/08/11, indicating the presence of ""Normal Skin Flora. No potential pathogens isolated."" A urine culture completed on 03/14/11 revealed the presence of [MEDICATION NAME] faecalis but [MEDICAL CONDITION]. The 2011 monthly surveillance reports did not identify Resident #103 as having an infection due [MEDICAL CONDITION]. During an interview Employee #67 at 2:00 p.m. on 04/12/11, she was asked to provide documentation of the initial reason for placing the resident in isolation. She returned at 3:30 p.m., stating she had located nothing on the chart, but she presented laboratory reports that had been received by fax at 2:36 p.m. on 04/12/11. A urinalysis, collected on 11/10/10, indicated the resident had a urinary tract infection and the resulting culture reported the presence [MEDICAL CONDITION] on 11/13/10. The resident's care plan contained the following: ""RESOLVED: Notify physician and family / responsible party of condition and/or changes in condition - 12/21/10"" and ""RESOLVED: Contact isolation due [MEDICAL CONDITION] of urine - 12/21/10."" The resident's abbreviated quarterly assessment dated [DATE] and comprehensive assessment dated [DATE] contained no indication of the presence of a UTI, the use of isolation precautions, or the presence of an MDRO (e.g.,[MEDICAL CONDITION]) for Resident #103. This was verified at 2:45 p.m. on 04/12/11 by Employee #168, who retrieved the information. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #20, and Employee #67 at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #103's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. An observation of Resident #103's room, at 9:30 a.m. on 04/13/11, revealed the contact isolation sign had been removed from the door. -- c) Resident #68 Medical record review revealed Resident #68 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had in place a suprapubic catheter. physician's orders [REDACTED]. Documentation in the medical record found the catheter was changed on 08/24/10 and was not changed after that until 02/03/11. Prior to that, on 02/01/11, the resident was seen by his attending physician, who diagnosed the resident as having a UTI. There was no documentation in the record by the attending physician to reflect his awareness the monthly catheter changes had not been done as ordered. There was no documentation to reflect the nursing staff had acknowledged this failure to comply with the order, to include evidence of an investigation into this failure and/or notification by staff of this failure to the attending physician and/or the resident's medical power of attorney representative (MPOA). During an interview with a family member of Resident #68, he stated he had become concerned about his father's health on 02/01/11, when the resident was seen by his attending physician and found to have a UTI. On the following day (02/02/11), he questioned a nurse as to when the resident's suprapubic catheter had last been changed. The nurse did not know, and he contacted the resident's urologist who changes the catheter in his office. He reported the urologist told him the most recent catheter change, according to his records, had been 08/24/10. The family member stated he relayed this information to a nurse at the facility, and they arranged for the resident to go to the urologist's office the next day and have it changed. He stated he was very upset, because this was not the first time this had happened, and he contacted the facility's regional office. He stated he had been assured last year that the monthly catheter change would not be missed again, but it was. He reported that no one from the facility had informed him or Resident #68's MPOA that the incident had been investigated. A urine culture, collected on 01/17/11, reported growth of Proteus mirabilis, and the attending physician ordered Bactrim DS on 01/18/11. This antibiotic was discontinued when the sensitivity report indicated the organism was resistant to Bactrim, and on 01/20/11, the physician ordered another antibiotic ([MEDICATION NAME]), which was completed on 01/25/11. The resident was seen by the attending physician on 02/01/11 and was noted to have a UTI, but there was no evidence in the medical record that staff had notified the attending physician that the resident's suprapubic catheter had not been changed since 08/24/10. The resident was seen by his nephrologist on 02/10/11, and was also diagnosed with [REDACTED]. There was no evidence in the medical record that either the attending physician or the resident's MPOA received a full report regarding the amount of time that had lapsed between catheter changes. During an interview with the administrator at 11:15 a.m. on 04/12/11, she acknowledged she knew of no record of the incident except an e-mail, which she produced. The e-mail, dated 02/04/11, was from the regional director of operations to the administrator and relayed the son's complaint of missed physician appointments with his urologist and missed services. She stated this was her first knowledge of the missing urology visits and catheter changes. .",2014-08-01
11124,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,225,D,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to: immediately report allegations of neglect to officials as required by State law; conduct a thorough investigation into the alleged violations; and/or report the results on such an internal investigation to State officials for one (1) of nine (9) sampled residents, after the facility received a verbal complaint of neglect from Resident #68's family member and after receiving written notification from the facility's corporate office that they had also received a complaint from Resident #68's family containing allegations of neglect. Resident identifier: #68. Facility census: 111. Findings include: a) Resident #68 Medical record review revealed Resident #68 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had in place a suprapubic catheter. The record further indicated Resident #68 had not been hospitalized since his admission to the nursing home. The resident assessment instruments with assessment reference dates of 03/08/10 and 02/14/11, reviewed in the presence of the assessment coordinator (Employee #168) at 2:45 p.m. on 04/12/11, both indicated the resident was free of urinary tract infections (UTIs). The resident was severely cognitively impaired and could not make his needs known. -- physician's orders [REDACTED]. In addition to the admission orders [REDACTED]. Further review of the medical record found Resident #68's suprapubic catheter was not changed in March 2010, June 2010, and at any time during the period from 08/24/10 through 02/03/11. There were no documented reasons for the missed urology appointments / catheter changes. The resident's comprehensive care plan presently in effect contained the following interventions to be performed by the licensed nursing staff including: ""Monitor for and report to physician any signs of UTI... Suprapubic catheter to be changed per physician order [REDACTED]. Clean supra pubic cath site via sterile technique apply TAO (triple antibiotic ointment) and cover with drainage sponge and secure dressing Q (every) shift and PRN (as needed). Check for patency / urinary output of supra pubic catheter q shift."" (This last intervention was to be performed by either a nurse or a nurse aide.) -- Review of the nursing notes from 11/29/10 through 01/20/11 found no documented evidence of any on-going assessment of the status of the resident's suprapubic catheter or for the presence of any signs / symptoms of a UTI, although the resident was diagnosed with [REDACTED]. -- A urine culture (from a specimen collected on 01/17/11) reported growth of Proteus mirabilis, and the attending physician ordered Bactrim DS on 01/18/11. The Bactrim DS was discontinued when the sensitivity report indicated the organism was resistant this drug, and on 01/20/11, the physician ordered another antibiotic ([MEDICATION NAME]) to be administered via intravenously, which was completed on 01/25/11. During the treatment period, the nursing notes documented, on 01/20/11, 01/21/11, and 01/23/11, that Resident #68 was ""sleeping a lot"", and that, on 01/21/11, his daughter was concerned that he was holding food in his mouth. On 01/24/11, a nursing note stated, ""Family in to visit @ supper. Stated 'He's so much more alert ...'"" -- The resident was seen by the attending physician on 02/01/11 and was noted to have another UTI. The resident was seen by his nephrologist on 02/10/11, who also diagnosed him with a UTI due to a culture report of Escherichia coli (E coli) present in his urine. There was no documentation in the medical record by the attending physician to reflect his awareness the monthly urology visits and catheter changes had not been performed as ordered since 08/24/10. There was no documentation to reflect the nursing staff had acknowledged this failure to comply with the order, to include evidence of an investigation into this failure and/or notification by staff of this failure to the attending physician and/or the resident's medical power of attorney representative (MPOA). There was no evidence in the medical record that either the attending physician or the resident's MPOA received a full report regarding the amount of time that had lapsed between catheter changes. -- During an interview with a family member of Resident #68, he stated he had become concerned about his father's health on 02/01/11, when the resident was seen by his attending physician and found to have a UTI. The resident had been treated with IV antibiotics from 01/18/11 through 01/25/11, and the family thought it was too soon for another infection. On the following day (02/02/11), he questioned a nurse as to when the resident's suprapubic catheter had last been changed. The nurse did not know, so he contacted the resident's urologist who performed the catheter changes in his office. The family member reported the urologist told him the most recent catheter change had occurred on 08/24/10. The son stated that he relayed this information to a nurse at the facility and demanded to know why the catheter had not been changed monthly as ordered. He stated the nurse looked in the chart but gave him no answer. Although the facility arranged for the resident to go to the urologist's office the next day and have the catheter changed, no one contacted either him or his brother, who was the resident's medical power of attorney representative (MPOA). The resident was sent to the urologist on 02/03/11, and his catheter was changed. The consultation report returned with the resident stated in all capital letters and underlined, ""NEEDS SP TUBE CHANGED EVERY MONTH."" He stated he was very upset, because this was not the first time this had happened, and when he had not been contacted by the facility by 02/04/11, he contacted the facility's corporate office. He stated he had been assured last year that the monthly catheter change would not be missed again, but it was. In addition to the missed catheter changes, he complained that day shift staff did not put his father's glasses on so he could see and that the staff kept getting his father's chair mixed up with others that were not large enough for him and caused him to be uncomfortable. The family member stated the administrator subsequently contacted him by phone, in response to his complaint to the corporate office, and told him that his brother had authorized the trial use of a smaller chair and that she would see that the resident's glasses were put on daily. She apologized that his father's catheter had not been changed as scheduled and said she would talk to his brother about it, as he was the MPOA. He stated that no one from the facility made an follow-up contact with him or his brother (the resident's MPOA) with the results of an internal investigation into the missed catheter changes. -- A review of the incident / accident reports, concern / grievance records, and self-reported allegations of abuse / neglect from 01/01/11 through this survey (04/13/11) failed to find any documentation of the concerns expressed by Resident #68's family regarding the catheter changes not occurring as ordered. There was no documentation in his medical record, including the care plan meetings, acknowledging that his catheter changes had been missed, nor was there any evidence to reflect the facility had taken any steps to investigate how these omissions of physician-ordered care had occurred. -- During an interview with the administrator at 11:15 a.m. on 04/12/11, she acknowledged she knew of no record of the incident except an e-mail, which she produced. The e-mail, dated 02/04/11, was from the corporate office to the administrator and relayed the family member's complaint of missed physician appointments with his urologist and missed services and other concerns. She stated this was her first knowledge of the missing physician's visits and catheter changes. She felt that her email reply to the corporate office was sufficient action in this instance. The following actions taken in response to the family member's complaints were recorded as follows in an e-mail from the administrator to her corporate office (quoted as typed): ""Spoke with the son who made the call but have not been able to reach the actual POA son. I can find no evidence that the gentleman was in the wrong Broda chair. This is a chair purchased especially for him and there is no other identical to it in the facility. I did tell him that we had tried his father in a different version of the chair X1 (one time) to see the feasibility of using it to transport to the shower room because his dad's chair is quite wide but does fit. ... ""It is common knowledge that this gentleman sometimes takes his glasses off and lays them on his lap. I have never seen him without his glasses. I usually see him every day in his room as well as in the dining room when I help assist residents with lunch. ""I did apologize to the gentleman as he was correct that the suprapubic catheter had not been changed as scheduled. The resident had gone to see his nephrologist but also needed to see his urologist. I think brought about confusion on the transports. This has been resolved and prescheduled for the next 6 months. ""(Family member's name) thanked me for returning his call and I encouraged him to call me at anytime as I would be happy to resolve any issues personally. I have talked to this gentleman in the past on other issues but was unaware of this concern. I will also talk to the POA to let him know I have followed up on the concern."" The administrator acknowledged she had not considered these complaints to be allegations of neglect. .",2014-08-01
11125,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,280,D,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to correctly revise the care plan for one (1) of nine (9) sampled residents, resulting in the deletion of interventions for a stated existing problem. According to the resident ' s current physician orders, the resident was to be in contact isolation. Observation of the resident ' s room found a posting announcing that contact precautions were to be used when caring for this resident. Review of the resident ' s current care plan found all references to the use of contact isolation precautions had been resolved / removed in December 2010. Resident identifier: #103. Facility census: 111. Findings include: a) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a urinary tract infection [MEDICAL CONDITION] on 11/10/10, and contact isolation due [MEDICAL CONDITION] on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. Review of Resident #103's current care plan found no mention of the use of contact isolation precautions. During an interview with the director of care delivery for the North unit (Employee #20) at 8:50 a.m. on 04/13/11, she confirmed that Resident #103 was in contact isolation. After reviewing the resident ' s current care plan presently, Employee #20 confirmed the care plan did not address the isolation. Employee #20 subsequently presented the following information from her computer: ""RESOLVED: Notify physician and family / responsible party of condition and/or changes in condition - 12/21/10"" and ""RESOLVED: Contact isolation due [MEDICAL CONDITION] of urine - 12/21/10."" Employee #20 agreed that, as long as, Resident #103 was in contact isolation, the interventions should continue in the care plan. .",2014-08-01
11126,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,441,F,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, review of facility infection control policies, and staff interview, the facility failed to establish and maintain an infection control program that investigates, controls, and prevents infections in the facility; decides what procedures, such as isolation, should be applied to an individual resident; and maintains accurate and complete records of incidents and corrective actions related to infections. These deficient practices resulted in three (3) of five (5) sampled residents remaining in contact isolation for extended periods of time after it was no longer required. This had the potential to affect all residents. Resident identifiers: #105, #103, and #59. Facility census: 111. Findings include: a) Resident #105 During the general tour at 10:30 a.m. on 04/11/11, observation found Resident #105 sitting in a chair in his room on the South unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #79) confirmed Resident #105 was in isolation. A review of the treatment book revealed Resident #105 was in contact isolation since 12/14/10 for Methicillin-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #105's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Neither the hospital discharge summary dated 10/18/10, nor the facility's history and physical dated 10/22/10, provided documentation that a MRSA infection had been present at the time of his admission, and a urine culture completed on 11/19/10 was negative for MRSA. The resident was ordered Bactrim on 12/09/10, and a urine specimen for culture and sensitivity (C&S) was sent to the laboratory. The urine culture was reported as positive for MRSA on 12/13/10, and the physician ordered ""Contact Isolation for MRSA in urine"" on 12/14/10. The lab report revealed Bactrim was an appropriate treatment for [REDACTED]. A urine culture completed on 12/23/10 was negative for growth. During an interview with the director of care delivery (DCD) for the South unit (Employee #67) at 3:10 p.m. on 04/11/11, she stated, after reviewing the resident's medical record, that she could find no reason for the isolation precautions to remain in place. An observation, at 1:20 p.m. on 4/12/11, revealed Resident #105's room was still posted with a contact isolation sign. During an interview with the director of nursing (DON - Employee #166 at 9:30 a.m. on 04/13/11, she acknowledged Resident #105 was in isolation, but she expressed surprise that it had been in effect for so long and stated she would follow up on it. The DON (who was the facility's infection control coordinator) also acknowledged that Resident #105 had not been listed on any of the 2011 monthly surveillance reports due to MRSA. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #67, and the DCD for the North unit (Employee #20) at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #105's physician that he no longer exhibited signs / symptoms of a urinary tract infection (UTI) and/or his most recent lab report was negative for MRSA. None was offered at the time of exit. The resident was not being followed on any of the 2011 monthly surveillance logs, as part of the facility's infection control program. -- b) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 for MRSA in urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a UTI on 11/10/10, and contact isolation due to MRSA on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. Further review of the medical record revealed a urine culture completed on 01/08/11, indicating the presence of ""Normal Skin Flora. No potential pathogens isolated."" A urine culture completed on 03/14/11 revealed the presence of [MEDICATION NAME] faecalis but not MRSA. During an interview Employee #67 at 2:00 p.m. on 04/12/11, she was asked to provide documentation of the initial reason for placing the resident in isolation. She returned at 3:30 p.m., stating she had located nothing on the chart, but she presented laboratory reports that had been received by fax at 2:36 p.m. on 04/12/11. A urinalysis, collected on 11/10/10, indicated the resident had a urinary tract infection and the resulting culture reported the presence of MRSA on 11/13/10. Although the monthly recapitulation of physician's orders [REDACTED].#103 no longer required isolation. During an interview with the DON, Employee #20, and Employee #67 at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #103's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative for MRSA. None was offered at the time of exit. An observation of Resident #103's room, at 9:30 a.m. on 04/13/11, revealed the contact isolation sign had been removed from the door. The 2011 monthly surveillance reports did not identify Resident #103 as having an infection due to MRSA. -- c) Resident #59 During the general tour at 11:20 a.m. on 04/11/11, observation found Resident #59 in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. Employee #112 confirmed Resident #59 was in isolation. A review of the treatment book revealed Resident #59 was presently in contact isolation for Clostridium difficile (C diff) in his stool. Review of Resident #59's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Review of Resident #59's medical record revealed laboratory results dated [DATE], with a note at the bottom of the page stating: ""C Diff & Blood cx (culture): Pending."" There was no evidence in the medical record, including the resident's admission history and physical, that verified the presence of active[DIAGNOSES REDACTED]. During an interview with Employee #20 at 8:45 a.m. on 04/13/11, when asked if there had been any follow-up with the lab, she replied she had not been aware of the notation written at the bottom of the 03/22/11 lab report. She contacted the lab and asked the lab to fax to the facility the results of stool and blood cultures collected on 03/18/11. During an interview with the DON / infection control coordinator and Employee #20 at 10:30 a.m. on 04/13/11, they acknowledged the[DIAGNOSES REDACTED] infection had not been verified, the physician was not notified of the lab results, and the resident was still in contact isolation. The March 2011 monthly surveillance log listed Resident #59 as having[DIAGNOSES REDACTED]"" for which, on 03/23/11, he was in contact isolation and receiving an antibiotic. The column for ""culture"" stated ""Stool"", but the date of the results was blank. There had been no follow-up to determine confirmation of the infection and, if necessary, confirmation of the appropriateness of the antibiotic. -- d) A review of the facility's infection control manual (reviewed and revised on 01/22/11, as indicated by signatures of the administrator, medical director, DON, etc.) found the following excerpts: 1. Under the heading ""Regulatory Guidelines"": ""- Define nosocomial or center acquired infections and communicable diseases ""- Identify, document and investigate nosocomial infections and communicable diseases ""- Use isolation procedures and requirements for infected, at risk and immunosuppressed patients ""- Define authority, indications, and procedures for obtaining and acting upon microbiological cultures and isolating patients"" - Under the heading ""Infection Control Coordinator"": ""The following activities are performed as directed or clinically indicated: ""- Collect and analyze information on in-house infections ""- Monitor appropriateness of precautionary procedures for individual patients ""- Maintain records of infections, procedures, outcomes related to infections and risk minimizing activities ""- Review infection and prevalence rates monthly providing recommendations to the Quality Assurance and Assessment Committee when indicated ""- Provide monthly and quarterly summaries for the Quality Assessment and Assurance Committee"" - 2. Under the heading ""Monthly Surveillance"": ""Information about infections is gathered, monitored and tracked throughout the month. The information is reviewed by the infection control coordinator for trend identification that may require outbreak investigations. Results are reviewed during the Eagle Room process and Quality Assessment and Assurance Committee meetings."" - 3. Under the heading ""Monthly Surveillance Log"": ""The infection control coordinator manages the process of completing the Monthly Surveillance Log continuously throughout the month."" -- e) During an interview with the DON / infection control coordinator and the DCDs for both units (Employees #20 and #67) at 12:10 p.m. on 04/13/11, they acknowledged that Residents #105, #103, and #59 no longer need to be in isolation. The DON explained that Employees #20 and #67 had the delegated responsibility to complete the monthly surveillance logs on their respective units. The 2011 South unit logs did not include any information about the results of cultures (identified infectious organisms), and Employee #67 verified she did not include this. The North unit logs also did not include final culture results for each month. All three (3) of the nurses admitted there was no information collected by location that would enable them to identify ""clusters"" of like-organisms. The DON / infection control coordinator stated she had not realized the monthly reports were not being completed. She stated that culture reports were discussed in stand-up meetings as they were received, but she had no explanation for the lack of any documentation to support this. The DON / infection control coordinator presented two (2) examples of the infection control monthly report that were forwarded to the quality assurance and assurance (QAA) committee for review. The examples were short one-paragraph narrative statements which included no trending or statistical information. The fact that three (3) residents had been inappropriately retained in isolation for months reflected a failure by the facility to accurately collect and analyze information on in-house infections. -- f) When meeting with the DON / infection control coordinator at 9:45 a.m. on 04/13/11, she was asked for the policy upon which the facility was to base a determination as to residents were to be removed from isolation. The DON presented two (2) pages of information from the Centers for Disease Control and Prevention (CDC) ""Issues in Healthcare Settings"", and she stated they go by these guidelines, but she could not point out anything in the documents that provided guidance in making this determination. There was the only following statement: ""Adopt a policy for deciding when patients can be removed from isolation..."" The DON then acknowledged the facility had no policy establishing a standard for stopping isolation and/or determining that a resident was now ""colonized"" instead of with an ""active"" infection. .",2014-08-01
11127,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,520,F,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, facility policy review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify the quality deficiencies in the infection control program, of which the QAA committee should have been aware, and failed to develop and implement a plan to correct these quality deficiencies. This had the potential to affect all residents. Resident identifiers: #105, #103, and #59. Facility census: 111. Findings include: a) Resident #105 During the general tour at 10:30 a.m. on 04/11/11, observation found Resident #105 sitting in a chair in his room on the South unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #79) confirmed Resident #105 was in isolation. A review of the treatment book revealed Resident #105 was in contact isolation since 12/14/10 for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #105's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Neither the hospital discharge summary dated 10/18/10, nor the facility's history and physical dated 10/22/10, provided documentation that [MEDICAL CONDITION] infection had been present at the time of his admission, and a urine culture completed on 11/19/10 was negative [MEDICAL CONDITION]. The resident was ordered Bactrim on 12/09/10, and a urine specimen for culture and sensitivity (C&S) was sent to the laboratory. The urine culture was reported as positive [MEDICAL CONDITION] on 12/13/10, and the physician ordered ""Contact Isolation [MEDICAL CONDITION] in urine"" on 12/14/10. The lab report revealed Bactrim was an appropriate treatment for [REDACTED]. A urine culture completed on 12/23/10 was negative for growth. During an interview with the director of care delivery (DCD) for the South unit (Employee #67) at 3:10 p.m. on 04/11/11, she stated, after reviewing the resident's medical record, that she could find no reason for the isolation precautions to remain in place. An observation, at 1:20 p.m. on 4/12/11, revealed Resident #105's room was still posted with a contact isolation sign. During an interview with the director of nursing (DON - Employee #166 at 9:30 a.m. on 04/13/11, she acknowledged Resident #105 was in isolation, but she expressed surprise that it had been in effect for so long and stated she would follow up on it. The DON (who was the facility's infection control coordinator) also acknowledged that Resident #105 had not been listed on any of the 2011 monthly surveillance reports due [MEDICAL CONDITION]. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #67, and the DCD for the North unit (Employee #20) at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #105's physician that he no longer exhibited signs / symptoms of a urinary tract infection [MEDICAL CONDITION] and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. The resident was not being followed on any of the 2011 monthly surveillance logs, as part of the facility's infection control program. -- b) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 [MEDICAL CONDITION] in urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a UTI on 11/10/10, and contact isolation due [MEDICAL CONDITION] on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. Further review of the medical record revealed a urine culture completed on 01/08/11, indicating the presence of ""Normal Skin Flora. No potential pathogens isolated."" A urine culture completed on 03/14/11 revealed the presence of [MEDICATION NAME] faecalis but [MEDICAL CONDITION]. During an interview Employee #67 at 2:00 p.m. on 04/12/11, she was asked to provide documentation of the initial reason for placing the resident in isolation. She returned at 3:30 p.m., stating she had located nothing on the chart, but she presented laboratory reports that had been received by fax at 2:36 p.m. on 04/12/11. A urinalysis, collected on 11/10/10, indicated the resident had a urinary tract infection and the resulting culture reported the presence [MEDICAL CONDITION] on 11/13/10. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #20, and Employee #67 at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #103's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. An observation of Resident #103's room, at 9:30 a.m. on 04/13/11, revealed the contact isolation sign had been removed from the door. The 2011 monthly surveillance reports did not identify Resident #103 as having an infection due [MEDICAL CONDITION]. -- c) Resident #59 During the general tour at 11:20 a.m. on 04/11/11, observation found Resident #59 in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. Employee #112 confirmed Resident #59 was in isolation. A review of the treatment book revealed Resident #59 was presently in contact isolation for [MEDICAL CONDITION] (C diff) in his stool. Review of Resident #59's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Review of Resident #59's medical record revealed laboratory results dated [DATE], with a note at the bottom of the page stating: ""C Diff & Blood cx (culture): Pending."" There was no evidence in the medical record, including the resident's admission history and physical, that verified the presence of active[DIAGNOSES REDACTED]. During an interview with Employee #20 at 8:45 a.m. on 04/13/11, when asked if there had been any follow-up with the lab, she replied she had not been aware of the notation written at the bottom of the 03/22/11 lab report. She contacted the lab and asked the lab to fax to the facility the results of stool and blood cultures collected on 03/18/11. During an interview with the DON / infection control coordinator and Employee #20 at 10:30 a.m. on 04/13/11, they acknowledged the[DIAGNOSES REDACTED] infection had not been verified, the physician was not notified of the lab results, and the resident was still in contact isolation. The March 2011 monthly surveillance log listed Resident #59 as having[DIAGNOSES REDACTED]"" for which, on 03/23/11, he was in contact isolation and receiving an antibiotic. The column for ""culture"" stated ""Stool"", but the date of the results was blank. There had been no follow-up to determine confirmation of the infection and, if necessary, confirmation of the appropriateness of the antibiotic. -- d) A review of the facility's infection control manual (reviewed and revised on 01/22/11, as indicated by signatures of the administrator, medical director, DON, etc.) found the following excerpts: 1. Under the heading ""Regulatory Guidelines"": ""- Define nosocomial or center acquired infections and communicable diseases ""- Identify, document and investigate nosocomial infections and communicable diseases ""- Use isolation procedures and requirements for infected, at risk and immunosuppressed patients ""- Define authority, indications, and procedures for obtaining and acting upon microbiological cultures and isolating patients"" - Under the heading ""Infection Control Coordinator"": ""The following activities are performed as directed or clinically indicated: ""- Collect and analyze information on in-house infections ""- Monitor appropriateness of precautionary procedures for individual patients ""- Maintain records of infections, procedures, outcomes related to infections and risk minimizing activities ""- Review infection and prevalence rates monthly providing recommendations to the Quality Assurance and Assessment Committee when indicated ""- Provide monthly and quarterly summaries for the Quality Assessment and Assurance Committee"" - 2. Under the heading ""Monthly Surveillance"": ""Information about infections is gathered, monitored and tracked throughout the month. The information is reviewed by the infection control coordinator for trend identification that may require outbreak investigations. Results are reviewed during the Eagle Room process and Quality Assessment and Assurance Committee meetings."" - 3. Under the heading ""Monthly Surveillance Log"": ""The infection control coordinator manages the process of completing the Monthly Surveillance Log continuously throughout the month."" -- e) During an interview with the DON / infection control coordinator and the DCDs for both units (Employees #20 and #67) at 12:10 p.m. on 04/13/11, they acknowledged that Residents #105, #103, and #59 no longer need to be in isolation. The DON explained that Employees #20 and #67 had the delegated responsibility to complete the monthly surveillance logs on their respective units. The 2011 South unit logs did not include any information about the results of cultures (identified infectious organisms), and Employee #67 verified she did not include this. The North unit logs also did not include final culture results for each month. All three (3) of the nurses admitted there was no information collected by location that would enable them to identify ""clusters"" of like-organisms. The DON / infection control coordinator stated she had not realized the monthly reports were not being completed. She stated that culture reports were discussed in stand-up meetings as they were received, but she had no explanation for the lack of any documentation to support this. The DON / infection control coordinator presented two (2) examples of the infection control monthly report that were forwarded to the QAA committee for review. The examples were short one-paragraph narrative statements which included no trending or statistical information. The fact that three (3) residents had been inappropriately retained in isolation for months reflected a failure by the facility to accurately collect and analyze information on in-house infections. -- f) When meeting with the DON / infection control coordinator at 9:45 a.m. on 04/13/11, she was asked for the policy upon which the facility was to base a determination as to residents were to be removed from isolation. The DON presented two (2) pages of information from the Centers for Disease Control and Prevention (CDC) ""Issues in Healthcare Settings"", and she stated they go by these guidelines, but she could not point out anything in the documents that provided guidance in making this determination. There was the only following statement: ""Adopt a policy for deciding when patients can be removed from isolation..."" The DON then acknowledged the facility had no policy establishing a standard for stopping isolation and/or determining that a resident was now ""colonized"" instead of with an ""active"" infection. -- g) During an interview with the administrator at 3:15 p.m. on 04/12/11, she stated the facility held QAA committee meetings monthly and that the DON / infection control coordinator reported to the QAA committee each month. In a follow-up meeting with the administrator at 12:45 p.m. on 04/13/11, the findings with respect to omissions in the monthly surveillance reports (e.g., final culture reports, locations of residents with infections, etc.) were reported. The administrator stated she was not aware the monthly surveillance reports were not being completed. The absence of trending and/or statistical information, in the reports provided to the QAA committee by the DON / infection control coordinator for at least the past three (3) months, was not recognized by members of the QAA committee. When asked how long it had been since the QAA committee had received trending and/or statistical information, the administrator had no response. No additional information had been received prior to exit.",2014-08-01
11128,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,278,D,1,0,2HR511,"**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 assessment instruments for one (1) of nine (9) sampled residents accurately reflected the resident ' s status with respect to the presence of a multi-drug resistant organism (MDRO) infection and the use of contact isolation precautions. Resident identifier: #103. Facility census: 111. Findings include: a) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a urinary tract infection [MEDICAL CONDITION] on 11/10/10, and contact isolation due [MEDICAL CONDITION] on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. The resident's care plan contained the following: ""RESOLVED: Notify physician and family / responsible party of condition and/or changes in condition - 12/21/10"" and ""RESOLVED: Contact isolation due [MEDICAL CONDITION] of urine - 12/21/10."" The resident's abbreviated quarterly assessment dated [DATE] and comprehensive assessment dated [DATE] contained no indication of the presence of a UTI, the use of isolation precautions, or the presence of an MDRO (e.g.,[MEDICAL CONDITION]) for Resident #103. This was verified at 2:45 p.m. on 04/12/11 by Employee #168, who retrieved the information. During an interview with the director of nursing / infection control coordinator (Employee #166), the director of care delivery (DCD) for the North unit (Employee #20), and the DCD for the South unit (Employee #67) at 12:10 p.m. on 04/13/11, they were asked if they were aware that two (2) of the resident assessment instruments completed for Resident #103 did not accurately reflect the resident was in isolation or that he had a MDRO infection. None of them had a response. .",2014-08-01
11129,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-06-23,431,D,1,0,2HR512,". Based on observation, staff interview, and record review, the facility failed to provide safe and secure storage of two (2) prescribed topical medications for two (2) of ten (10) sampled residents, and failed to secure one (1) unlabeled topical medication. Resident identifiers: #25 and #62. Facility census: 117. Findings include: a) Residents #25 and #62 Observation, on 06/21/11 at approximately 12:15 p.m., found two (2) treatment carts in a central shower room stall on the 100-200 halls. A container labeled Silver Sulfadiazine Cream was on the top of one (1) treatment cart. The container was labeled for Resident #25. The pharmacy label indicated the Silver Sulfadiazine Cream was for topical use only. A container in a zip lock bag labeled ""Nystop Pwd"" (powder) was on the top of one (1) treatment cart. The container was labeled for Resident #62. The pharmacy label indicated the powder was for topical use only. b) On the initial tour conducted on 06/21/11 at approximately 12:15 p.m., observation through the open central shower room door found a tube of medication on top of a can lid. The unlabeled tube was identified as Medline Remedy Calazime. An interview was conducted by the second surveyor with two (2) nurses (Employee #173 and 117) who could not identify who the Calazime was used for. .",2014-08-01
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
11131,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,242,D,1,0,UJUP11,". Based on medical record review, observation, and staff interview, the facility failed to honor a resident's right to receive a Kosher diet, in recognition of her lifelong religious beliefs and practices, and failed to communicate the specifics of how a Kosher diet was to be prepared to the dietary kitchen staff. This was true for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #48. Facility census: 124. Findings include: a) Resident #48 Review of the resident's care plan, created on 11/22/10, revealed the following problem statement: ""Resident is at nutritional risk due to receiving a mechanically altered diet. Due to Jewish religious beliefs, resident eats Kosher and has several food preferences. She had a significant wt. (weight) loss x (symbol for times) 30 days."" Approaches to this problem included: ""Honor food preferences within meal plan and maintain resident's cultural food preferences as obtained by FSD (food service director)."" Observation, on 04/27/11 at approximately 12:10 p.m., revealed Resident #48 was served a pork tenderloin while in the North dining room. Employee #101 (a nursing assistant) delivered a tray to the resident at her table. When Employee #101 removed the covering from the resident's plate, he returned the tray to a dietary employee and stated the resident was not to be served pork. The dietary staff then prepared another tray for the resident. -- On 04/27/11 at approximately 1:45 p.m., the food service director (FSD - Employee #133) and the food service assistant (Employee #180) were asked how they would prepare a Kosher diet. Employee #133 stated a Kosher diet means ""no pork, no pork products, and meat and cheese cannot be on the same plate together."" Employee #180 stated, ""Meat and dairy cannot be touching on the same plate."" Employee #180 also stated if the facility was to serve a ""real Kosher diet"", the kitchen would have to purchase separate pots and pans just to cook the resident's food. He explained that if pork was cooked in a pan, the resident would not be able to eat anything else cooked in this pan. Employee #180 stated he had spoken with the resident's family and the family stated the facility could serve a ""mellow Kosher diet"". When asked how they conveyed this information to the dietary employees, Employee #133 stated the specifications were on the resident's tray card. The tray card for Resident #48, when observed, documented the resident had dislikes of pork and bacon and was to receive 4 ounces of milk. Employee #180 verified the facility's care plan approach to ""maintain resident's cultural food preferences as obtained by the FSS"" was not sufficiently detailed on the tray card for dietary staff to know how to prepare and serve this resident's food. .",2014-08-01
11132,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-14,225,E,1,0,VVWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on record review, policy review, and staff interview, the facility failed to substantiate as neglect the lack of care for five (5) of ten (10) sampled residents (#1, #36, #39, #54, and #75), as defined in the facility's abuse prohibition policy. After shift change at approximately 3:30 p.m. on 04/04/11, the oncoming CNA (Employee #10) reported to the licensed practical nurse (LPN - Employee #77) having found these five (5) residents ""soaked"" with urine, with Resident #75 complaining of being wet and burning, and Resident #39 having been found ""lying in a bed of urine, still wet with dry yellow rings around the edges of the draw sheet"". The facility's internal investigation identified Employee #111 as the CNA having been assigned to care for these residents on the 7:00 a.m. to 3:00 p.m. (7-3) shift on 04/04/11. Review of the facility's five-day follow-up reports and interview with the administrator (Employee #69) and the manager of clinical operations (Employee #156), on the afternoon of 04/13/11, found the facility did not determine that Employee #111 had neglected the above residents. Resident identifiers: #1, #36, #39, #54, and #75. Facility census: 124. Findings include: a) Residents #1, #36, #39, #54, and #75 Review of the facility's internal investigations into allegations of abuse / neglect found documentation stating that, when Employee #10 came on duty for the 3-11 shift on 04/04/11 and began his first rounds at 3:05 p.m., he found five (5) of the twelve (12) residents who had been assigned to Employee #111 (the 7-3 shift CNA) were saturated with urine. - In a statement written by Employee #10 on 04/04/11, he stated (quoted as written): ""On 4-4-11 at 3:05 pm I (name of Employee #10) was getting report from CNA (name of Employee #111). She stated to me that she had just got finished doing her first round a couple of minutes ago and that everyone was dry and clean. That's when (name of Resident #75) in (room number) on south unit, stated she was wet an burning. Proceeded to check resident and she was soaking wet. ""CNA (name of Employee #111) was still present at that time. I told (Employee #111) that she could go head and leave and that I would go head an change her, because I thought (Resident #75) was just wet from consuming a lot of fluids early in the day. But as I proceeded to continue my round It became a pattern. (Name of Resident #1) resident in (room number) was soaked with urine in her brief, after changing her proceeded to (room number) (name of Resident #36) where I found him soaked even though he has a foley (indwelling urinary catheter), it leaks. Proceeded to (room number) beds A & B resident, both resident (#54 and #39) soaked with exceptions of (name of Resident #39) was a total bed. Meaning she was lying in a bed of urine still wet with dry yellow rings around edge of draw sheet indicating she's been lying in it for awhile. That's when I reported & showed nurse (Employee #77), because that was just to many residents soaked like that at one time."" - In a statement written by Employee #77 on 04/04/11, she stated (quoted as written): ""On 4/4/11 at approximately 3:30 p.m. 3-11 CNS made this nurse aware that resident in (room number) bed B (Resident #39) was wet, stated 'I need you to come look at something' checked residents draw sheet and brief. Noted to be wet, draw sheet dry /c (with) brown / yellow ring noted."" - 1. Resident # 75 According to Section G of a minimum data set (MDS) assessment dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 2. Resident #1 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 3. Resident #36 According to Section G of an MDS dated [DATE], this [AGE] year old male was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 4. Resident #39 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 5. Resident #54 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. -- b) Review of the facility's internal investigations into allegations of neglect involving each of the above residents found the same result (quoted as written): ""After investigation it was determined that the allegation of neglect was unsubstantiated. CNA (name of Employee #111) was re-educated on changing residents that are incontinent and rounding closer to end of shift."" -- c) Review of the facility's policy titled ""1.0-WV Abuse Prohibition"" (effective 06/01/96 and revised 11/01/09) found the following definition: ""Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."" -- d) In an interview on the afternoon of 04/13/11, the administrator and the manager of clinical operations reported the facility did not determine that Employee #111 had neglected the above residents. --- Part II -- Based on record review and staff interview, the facility failed to immediately report two (2) of two (2) injuries of unknown source discovered when reviewing the facility's incident / accident reports from March 2011. Resident #22 was discovered to have purple bruises on the right and left buttocks on 03/28/11. Resident #84 had abrasions on the tops of both feet. The causes of these injuries were not witnessed, the residents could not relate to staff how they occurred, and the injuries were suspicious in nature due to their locations. Interview with the administrator, on 04/13/11 at 2:00 p.m., confirmed no immediate or follow-up reporting of these injuries was made to State agencies as required. Resident identifiers: #84 and #22. Facility census: 124. Findings include: a) Resident #84 Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report was initiated for Resident #84 on 03/15/11 at 3:00 p.m., for ""unwitnessed"" abrasions on the tops of both feet. The description of the incident stated (quoted as written), ""Abrasions noted to top of Right & Left feet. Previously noted to right foot on 3/3/11. Noted to left foot on 3/13/11."" The abrasion on the right foot measured 5 cm x 0.4 cm (with no depth), and the abrasion on the top of the left foot measured 9 cm x 0.5 cm (also with no depth). First aid was to include: ""RN assessment - cleanse abrasions, pat dry, apply SurePrep."" This report indicated the event(s) causing the abrasions were unwitnessed, and no known cause documented on the form. - Review of the facility self-reported events for March 2011 found these injuries were not immediately reported to State agencies (within no greater than twenty-four (24) hours of their discovery). - In an interview with the administrator and the manager of clinical operations on 04/13/11 at 1:45 p.m., they stated the injuries were not reported, because the facility knew what caused them. In a follow-up interview at 2:00 p.m. on 04/13/11, the administrator presented an incident / accident investigation form that had been completed by the facility on 03/18/11. - Review of the facility's investigation into this incident found under the heading ""Possible Causes for Incident"": ""Abrasions to bilateral top of feet may have been caused by socks or resident's position. Resident very restless @ (at) times."" - The facility investigated the injuries but failed to immediately report them to State agencies, and failed to provide follow-up reporting of the results of the internal investigation to State agencies as required. -- b) Resident #22 Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report involving Resident #22 dated 03/28/11, noting staff discovered bruises on the resident's right and left buttocks. The description of the incident stated (quoted as written), ""CNA notified this nurse of bruise on (L) & (R) buttock."" The description of the injury stated (quoted as written), ""Purple linear bruise (L) buttock 4 cm x 0.4 cm. Round purple bruise 0.3 x 0.3 cm."" This report indicated event causing the bruises was unwitnessed, and no known cause documented on the form. - Review of the facility self-reported events for March 2011 found these injuries were not immediately reported to State agencies (within no greater than twenty-four (24) hours of their discovery). - In an interview with the administrator and the manager of clinical operations on 04/13/11 at 1:45 p.m., they stated the injuries were not reported, because the facility knew what caused them. - In a follow-up interview at 2:00 p.m. on 04/13/11, the administrator presented an incident / accident investigation form that had been completed by the facility on 03/29/11. - Review of the facility's investigation into this incident found under the heading ""Possible Causes for Incident"": ""Bruises noted to be at area of where open shower chair lid is."" - The facility investigated the bruises but failed to immediately report them to State agencies, and failed to provide follow-up reporting of the results of the internal investigation to State agencies as required. .",2014-08-01
11133,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-14,309,G,1,0,VVWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to provide care and services for one (1) of ten (10) sampled residents to prevent an avoidable decline in the condition of a left foot abrasion. On 03/15/11, documentation in Resident #84's medical record described the presence of an ""intact"" abrasion across the top of the resident's left foot. On 03/16/11, a TED (compression) hose was applied to his foot to reduce [MEDICAL CONDITION]. A clarification order, also dated 03/16/11, directed nursing staff to: ""Check skin integrity below TED hose Q (every) shift."" On 03/27/11, facility documentation noted the wound had decreased in length, increased in width, and was described as being ""intact"" with a ""scab"" present. On 03/30/11, Resident #84 was sent to the hospital at the request of his family for evaluation of the wound. Hospital records revealed this resident had a Stage III pressure sore with damage down to the fascia and required antibiotic therapy for [MEDICAL CONDITION] (infection into the tissues). Medical record review disclosed skin assessments (which were to be done on every shift after the application of the compression hose) were not completed in accordance with a physician's orders [REDACTED].#84. Facility census: 124. Findings include: a) Resident #84 1. Medical record review, on 04/13/11, revealed this [AGE] year old male resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and answered simple questions appropriately but had some cognitive and perceptual deficits. His physician determined he lacked the capacity to understand and make informed medical decisions for himself, and his medical power of attorney (MPOA) was serving as his surrogate decision-maker. According to the resident's current comprehensive care plan, which was provided by the facility's staff development nurse (Employee #5) on 04/14/11, this resident was non-ambulatory and dependent upon staff for all activities of daily living (ADLs). -- 2. Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report was initiated for Resident #84 on 03/15/11 at 3:00 p.m., for ""unwitnessed"" abrasions on the tops of both feet. The description of the incident stated (quoted as written), ""Abrasions noted to top of Right & Left feet. Previously noted to right foot on 3/3/11. Noted to left foot on 3/13/11."" The abrasion on the right foot measured 5 cm x 0.4 cm (with no depth), and the abrasion on the top of the left foot measured 9 cm x 0.5 cm (also with no depth). First aid was to include: ""RN assessment - cleanse abrasions, pat dry, apply SurePrep."" Review of the facility's investigation into this incident (completed on 03/18/11) found under the heading ""Possible Causes for Incident"": ""Abrasions to bilateral top of feet may have been caused by socks or resident's position. Resident very restless @ (at) times."" -- 3. Review of nursing notes, dated 03/13/11 (prior to completion of the incident report) documented (quoted as typed): ""(Resident #84) has a new onset / change in skin integrity as evidenced by abrasion. Location: top of left foot. ... New orders obtained. Cleanse site with w/c, pat dry, apply non sting sureprep to site Qshift and leave open to air."" A nursing note, dated 03/15/11 at 12:28 p.m., stated: ""Lotion applied to bilateral feet per this nurse at this time. Feet dry. Left foot swollen. MPOA aware. Will address with MD."" A nursing note, dated 03/15/11 at 15:33 (3:33 p.m.), stated (quoted as typed): ""... New orders noted for ted hose, wound nurse consult D/T (due to) previously noted areas on top of feet, and A & D ointment to bilateral feet. MPOA aware of new orders."" A nursing note, dated 03/16/11 at 17:24 (5:24 p.m.), stated (quoted as typed): ""Order clarification for ted hose to be worn to left leg at all times. Check skin integrity Q shift below ted hose. ..."" -- 4. Review of his physician's orders [REDACTED]. Wound care nurse eval."" A notation on the order stated (quoted as written), ""done 3/15/11 3:45 p.m."" Another order was written later on 03/15/11 for: ""(1) A&D ointment to bilateral feet Q (every) shift D/T (due to) dry skin. (2) No sting sureprep to to (sic) top of left foot Q day D/T abrasion."" Further review found the following clarification order dated 03/16/11: ""TED hose to left leg at all times. Check skin integrity below TED hose Q shift."" On 03/30/11, an order was received to: ""Place TED hose on hold until abrasion to top of left foot is resolved."" Also on 03/30/11, an order was received to: ""Send resident to (local hospital) ER (emergency room ) for evaluation abrasion & swelling to left foot."" -- 5. An assessment recorded by nursing staff at the ER at 19:56 (7:56 p.m.) on 03/30/11 stated (quoted as typed): ""... Skin not intact. Pressure sore with damage down to fascia (Stage III) noted. Located on left ankle. Present on arrival (area on lateral ankle and at flexion point of joint). ..."" (Note: The definition of a Stage III pressure sore is: ""Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue."") Further review of the hospital records disclosed Resident #84 was treated in the ER with intravenous (IV) antibiotics ([MEDICATION NAME] and [MEDICATION NAME]), and he was discharged back to the facility with an order for [REDACTED]. According to the nursing notes, Resident #84 returned to the facility at 3:30 a.m. on 03/31/11. The physician's assistant saw Resident #84 on the afternoon of 03/31/11 and gave the following orders at 3:45 p.m.: ""1) D/C (discontinue) order for Sureprep to top of Lt (left) foot. 2) Cleanse top of Lt foot /c (with) wound cleanser, Pat dry. Apply [MEDICATION NAME] gel & cover /c dry dressing. Change daily & PRN. 3) Consult wound clinic. 4) Keflex 500 mg po (by mouth) qid (four (4) times a day) x 10 days for [MEDICAL CONDITION]."" -- 6. On 04/13/11, the facility's nurse practice educator (NPE), a registered nurse (RN - Employee #5) was asked for evidence of the weekly skin assessments and the skin integrity assessments (ordered on [DATE]) to be done on every shift following the application of the TED hose to Resident #84. Employee # 5 stated these assessments would have been recorded in the nursing notes on every shift. -- 7. Review of nursing notes from 03/16/11 (when the TED hose to the left foot was ordered) to 03/30/11 (when application of the TED hose was put ""on hold"") found no evidence of skin assessments of the left foot having been completed on every shift as ordered. - A nursing note, dated 03/17/11 at 9:27 a.m., stated: ""Previously noted abrasions to top of right foot and top of left foot continue. Skin continues to be very dry to bilateral feet. A & D ointment continues D/T dry skin. Applied per this nurse."" - A nursing note, dated 03/20/11 at 15:08 (3:08 p.m.), stated: ""... TED hose to left leg in place. ..."" There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 00:38 (12:38 a.m.), stated: ""... TED hose to LLE (left lower extremity) in place ..."" There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 12:16 p.m., stated: ""... TED hose in place to LLE. ..."" There was no indication the skin integrity had been checked. No further nursing notes were made regarding the TED hose until 03/27/11 at 18:49 (6:49 p.m.), when the nurse recorded (quoted as typed): ""... Resident medicated x 3 this shift, resident crying out in pain this evening during dinner crying out and stating to please put him in bed, could not tolerate the pain. Some pain relief noted after assisting resident back to bed. Resident continues with 25mcg [MEDICATION NAME] and [MEDICATION NAME] 10 Q4 prn (every 4 hours as needed) for pain. Ted hose removed from left leg and kept off due to abrasion to ankle with indentation from ted hose. ..."" - A nursing note, dated 03/29/11 at 13:48 (1:48 p.m.), stated: ""... MD PA (physician's assistant) in to see resident. ..."" -- 8. Review of a progress note related to physician service visit on 03/29/11 found the following under the heading ""Chief complaint / History of present illness"": ""... (L) ankle still has ulcer."" Under the heading ""Assessment / Plan"" was written: ""... (5) Abrasion / ulceration ..."" No description of this ulceration was recorded. A previous entry related to a physician service visit on 03/23/11 made no mention of the presence of this wound. An entry related to a physician service visit on 03/15/11 stated: ""... mild abrasion improving ..."" -- 9. Further review of nursing notes revealed a late entry by the wound nurse (Employee #72), entered at 15:30 (3:30 p.m.) on 03/29/11, stating: ""Went to room to evaluate abrasion to top of L (left) foot. Abrasion measurements obtained and noted to be increased. Scab intact. ..."" - A nursing note, on 03/30/11 at 17:20 (5:20 p.m.), revealed the resident's sister / MPOA had become concerned about the condition of the resident's left foot and stated she would like the resident to be sent to the hospital ER (emergency room ) to be evaluated by a ""real doctor"" for the abrasion and swelling of the left foot. - A nursing note, dated 03/30/11 at 18:50 (6:50 p.m.), stated the resident was transported to the hospital ER. (The resident returned to the facility at 3:30 a.m. the next morning.) -- 10. Review of the resident's Skin Integrity Report, completed by the wound nurse weekly, revealed the wound nurse began weekly observations and measurements of the abrasion to the top of Resident #84's left foot on 03/15/11. - When it was discovered on 03/15/11, documentation on the Skin Integrity Report described the abrasion as 9 cm in length and 0.5 cm in width with no depth, and the surrounding tissue and wound edges were described as healthy. - On 03/21/11, documentation on the Skin Integrity Report indicated the skin was intact, length was 9 cm, width was 0.5 cm, the surrounding tissue was healthy, and no drainage was present. - On 03/27/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab. The length was 5 cm, the width was 1.3 cm, the surrounding tissue was red, and the wound edges were healthy. - On 03/29/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab, the length was 2.1 cm and width was 5.1 cm. The surrounding tissues and wound edges were described as healthy with no drainage present. -- 11. According to the weekly Skin Integrity Report, between 03/21/11 and 03/27/11, the wound on top of the resident's left foot decreased in length (from 5 cm to 2.1 cm), increased in width (from 1.3 cm to 5.0 cm), and declined from being intact to being intact with a scab present. There were no nursing notes, physician progress notes [REDACTED].#84's medical record describing any changes that had occurred to the wound on his left foot between these two (2) Skin Integrity Reports. A progress note recording physician service visit on 03/29/11 noted ""(L) ankle still has ulcer"" and ""abrasion / ulceration"", although the terms ""ulcer"" and ""ulceration"" were not used by nursing staff in the facility when describing this wound - which was referred to only as an ""abrasion"" that was intact. An assessment of the resident's foot, completed by nursing staff in the hospital'sER on [DATE], described the skin on the resident's left foot as ""not intact"" and as being a Stage III pressure sore involving the fascia. This failure to monitor the skin integrity of the resident's left foot after applying the TED hose, which already had an abrasion across the top, resulted in delayed identification and treatment of [REDACTED].",2014-08-01
11134,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2011-04-21,225,D,1,0,WPZ611,". Based on medical record review, personnel record review, and staff interview, the facility failed to: (1) immediately report an allegation of neglect and/or report the results of an investigation to the appropriate state agencies in accordance with State law, for one (1) of thirteen (13) sampled residents, and (2) ensure that the professional nursing licenses of potential employees have been verified to be valid and/or free of actions by a court of law, by not checking the out of state licenses of two (2) of four (4) newly hired registered nurses (RNs). Resident identifier: #64. Employee identifiers: #2 and #4. Facility census: 63. Findings include: a) Resident #64 A review of the facility's grievance / complaint reports revealed Resident #64 reported to the social worker, on 03/14/11, that she had turned on her call light and requested pain medication three (3) times from two (2) nursing assistants, who entered her room and turned of the light. She stated it was only after the third request that the nurse finally came in and brought the pain medication. This allegation was documented as a grievance, statements were collected from the care staff working at the time of the reported incident, and the staff was counseled. However, this allegation of mistreatment and/or neglect was not reported to the State survey and certification agency, adult protective services, or the regional ombudsman, in accordance with State law. Furthermore, although an investigation was done, the results of the investigation was not reported to these same agencies, which is also a requirement. During an interview with the administrator and the director of nurses (DON) at 10:30 a.m. on 04/21/11, they acknowledged Resident #64 had been determined to possess the capacity to understand and make health care decisions, which was why they did a complete investigation and counseled the staff. They stated they just did not consider reporting it. -- b) Employees #2 and #4 The personnel records of two (2) newly hired RNs revealed both of them had stated in their written applications that they were licensed in the States of Virginia and Maryland, in addition to West Virginia. Although the status of their West Virginia RN licenses had been appropriately verified, the status of the licenses in the other two (2) States had not been verified. During an interview at 3:10 p.m. on 04/20/11, the administrator and Employee #3 (who was the person responsible for human resource activities) acknowledged, after reviewing their personnel files, that the out-of-state license checks had not been done.",2014-08-01
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
11139,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,246,E,1,0,DRNI11,". Based on observation, resident interview, record review, and staff interview, the facility failed to ensure each resident received reasonable accommodations of needs. During the initial tour of the facility, many residents were up in chairs or ambulating about the facility. Four (4) residents were observed in bed without access to their call light buttons. Another resident, who needed assistance, was found later that evening to be unable to reach his call light to summon assistance. Resident identifiers: #31, #34, #9, #40, and #20. Facility census: 51. Findings include: a) Resident #31 During the initial tour of the facility at approximately 4:50 p.m. on 04/13/11, observation found this resident's call light to be out of reach. The resident was in bed with the head of the bed elevated at approximately 75 degrees. His call light was on the handle of his bedside table, which was to his left and behind the head of the bed. When asked if he could reach his call light, he said he could not. -- b) Resident #34 At approximately 5:00 p.m. on 04/13/11, this resident's call light was noted to be on the floor beneath his bed. -- c) Resident #9 At 5:07 p.m. on 04/13/11, the resident was lying in his low bed on his back. His call light button was beneath the bed on the floor. When asked if he used his call light, he said he did but he could not reach it. He put his hand on the controller for his bed; when asked if that was what he used to call for help, he said it was just for the bed. At 7:30 p.m. on the same evening, his call bell button was again observed on the floor beneath his bed. -- d) Resident #40 At approximately 5:30 p.m. on 0413/11, observation found this resident sitting in a recliner next to her bed. Her call light was next to her, but it was underneath the cover on her bed. When asked where her call light was, she felt around for the button. It took her several minutes to locate the right cord. According to her quarterly minimum data set assessment, with an assessment reference date of 01/27/11, her vision was severely impaired. -- e) Resident #20 On 04/13/11 at 6:38 p.m., this resident motioned as though needing assistance. He said he was tired, did not feel well, and needed to go back to bed. When asked if he had rung his call bell, he said he had not - that he could not reach it. The resident was sitting up in a wheelchair with his overbed table in front of him. His call bell button was lying on his bed, several feet away. The overbed table was between the resident and the call button. The resident was handed his call button, which he rang at 6:40 p.m. -- f) On 04/15/11 at 1:55 p.m., a licensed practical nurse (Employee #15) was asked whether these five (5) residents were able to use their call bells. She said they could. .",2014-08-01
11140,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,274,D,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of medical records, staff interview, and resident interview, the facility had failed to conduct a comprehensive assessment within fourteen (14) days after a significant change in the resident's condition should have been identified. Review of medical records found one (1) of six (6) residents on the sample had declines in more than two (2) areas of activities of daily living (ADLs), continued weight loss, and a decline in continence. A significant change in status assessment had not been conducted in an attempt to identify possible causal factors. Resident identifier: #9. Facility census: 51. Findings include: a) Resident #9 Resident #9's most recent minimum data set assessments 3.0 (MDS) were reviewed. A quarterly assessment with an assessment reference date (ARD) of 10/29/10 was compared to a quarterly assessment with an ARD of 01/26/11. The following changes were noted between the 10/29/10 and 01/26/11 assessments: - Bed mobility improved from extensive assistance of two (2) to limited assistance of one (1); - Transfer abilities declined from limited assistance of two (2) to extensive assistance of two (2); - Walk in room and walk in corridor declined from extensive assistance of two (2) to did not occur; - Toilet use declined from limited assistance of two (2) to total dependence with the assistance of two (2); - Personal hygiene declined from limited assistance of one (1) to extensive assistance of two (2); - He had been coded as requiring human assistance to balance when moving from a sitting to standing position, walking, turning, and moving on and off of the toilet in October 2010, but the January 2011 assessment indicated these activities did not occur; - Bowel continence declined from continent to always incontinent - In October, the assessment was coded for significant weight loss with his weight entered as 164 pounds. In January, his weight had continued to decline and was listed as 154 pounds. Additionally, between the two (2) quarterly assessments, the resident had been hospitalized from [DATE] to 12/11/10 and again 12/17/10 to 12/26/10. These changes indicated a comprehensive assessment needed to be completed with the additional care area assessments (CAAs) completed. The CAAs would help identify causal factors and possible interventions to restore the resident to his previous ability levels or to prevent further declines. An interview with the MDS nurse (Employee #6), in mid morning on 04/15/11, found she had not done a significant change assessment. The criteria in the interpretive guidelines for F274 were briefly reviewed with the nurse, as it offered better guidance than the current RAI manual (which has been acknowledged by the Centers for Medicare and Medicaid). She acknowledged the need for a significant change assessment and began the assessment later that morning. A nursing assistant (Employee #36) was interviewed in the afternoon on 04/14/11, regarding this resident. She said she had tried to get him out of bed, but he refused. The last time she could remember him agreeing to get up in a chair had been about a month ago. She said he has had increased confusion. Also in the afternoon of 04/14/11, a nursing assistant (Employee #37) said the resident had been refusing to go take a shower for about four (4) to six (6) months. He would take a bed bath but refused to take a bath or shower. She said, at one time, they would get him up, but he would ""throw himself onto the floor so he could go back to bed."" The resident was interviewed at 10:00 a.m. on 04/15/11. He said he was feeling ""some better"" today. When asked if he ever got up in a chair, he said, ""No, I can't walk."" He was aware staff would get him up in a chair if he wanted - he said he knew that. Then he said he did not get up because his ""hind end is sore."" When asked if he would get up if his hind end was not sore, he quickly said, ""No."" The resident said he preferred to stay in bed and to be by himself. When asked about moving around in bed, he stated he would turn sometimes, but preferred to stay on his back. Due to Resident #9's refusal to get out of bed and to participate in any activities, it could not be determined that his decline was clinically avoidable. However, his declines did meet the criteria for a significant change in condition assessment. .",2014-08-01
11141,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,279,D,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, the facility had failed to develop and implement a care plan to address a resident's fluid restriction. The care plan was not developed to provide sufficient guidance to the nursing staff to ensure compliance with the physician's orders [REDACTED]. Additionally, the care plan included monitoring of the resident's intakes and outputs, but no method for this monitoring was implemented. One (1) of six (6) residents on the sample was affected. Resident identifier: #26. Facility census: 51. Findings include: a) Resident #26 Review of the resident's medical record, on 04/15/11, revealed a physician's orders [REDACTED].@ 10 AM and 2 PM @ snack pass."" 1. Review of the resident's care plan found it included: ""Fluid Restriction: 1200 ml Dietary and 300 ml Nursing - Serve 120 ml liquid @ 10 AM and 2 PM @ snack pass."" The plan was not developed to provide further guidance to nursing staff as to how much fluid could be given on a given shift, especially with consideration given to medication passes and other activities. 2. The care plan also had an intervention to monitor fluid intake and output. Further review of her record found there was inconsistent recordation of her intakes. When two (2) licensed practical nurses (LPNs - Employees #15 and #21) were asked where her fluid intakes were tracked, they said they would be on the appetite records and the hydration records. When asked if these were recorded in her medical record, they said there were no intake and output sheets for the individual resident. There was no effective method to allow for monitoring the resident's fluid intake and her output, to determine whether the fluid restriction was being implemented as ordered or to monitor her intake and output as identified in the care plan. .",2014-08-01
11142,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,309,E,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, staff interview, and observation, the facility failed to ensure each resident received the care and services to maintain his or her highest practicable levels of well-being in accordance with the plan of care. A resident experienced an acute episode of gastrointestinal (GI) bleeding, but his blood pressure was not checked for more than thirty (30) minutes after the staff was made aware he was ill. Another resident had an order for [REDACTED]. A resident who had recently begun to gain weight after having experienced a significant weight loss. He had also had declines in his abilities to perform activities of daily living. This resident was observed to not be positioned to facilitate feeding himself. Six (6) residents were found to have orders for nutritional supplements. The orders included instructions to record the percentage of the supplements the resident consumed. These percentages were not consistently recorded as ordered for six (6) of six (6) residents. Resident identifiers: #20, #26, #47, #9, #6, #26, #32 and #50. Facility census: 51. Findings include: a) Resident #20 On 04/13/11 at 6:38 p.m., this resident motioned as though needing assistance. He said he was tired, did not feel well, and needed to go back to bed. When asked if he had rung his call bell, he said he had not - that he could not reach it. The resident was sitting up in a wheelchair with his overbed table in front of him. His call bell button was lying on his bed, several feet away. The overbed table was between the resident and the call button. The resident rang his call bell at 6:40 p.m. after being handed his call bell. At 6:43 p.m., a nursing assistant came to the door to see what he needed. He told her he needed to go to bed because he did not feel well. The nursing assistant had a bag of soiled linen in her hand, so she could not enter the room. She summoned another nursing assistant and said she would be back as soon as she disposed of the linens. She returned at approximately 6:44 p.m., and the two (2) nursing assistants began to get ready to transfer him to his bed. The resident again said he felt like he was having trouble breathing and felt like he was going to pass out. One (1) of the nursing assistants checked to make sure the resident's oxygen was running as the other summoned the nurse. A licensed practical nurse (LPN - Employee #16) came to the room promptly. After speaking with the resident, checking his heart rate and respirations, she went to get the pulse oximeter with which to check his oxygen saturation. As the nurse re-entered the room, it was noted there was approximately 120 cc of a reddish fluid beneath the resident's wheelchair. This was pointed out to the staff. Initially it was thought to possibly be spilled juice, but closer inspection found it was not juice. The nurse attempted to obtain a reading of the resident's oxygen saturation level but was unable to do so. A registered nurse (RN - Employee #4) came to the resident's room to speak with Employee #16. She was informed of the resident's condition and that the fluid under his wheelchair appeared to be bloody. Employee #4 was advised the resident's oxygen saturation could not be obtained and she attempted to check several times before obtaining a reading. A stethoscope was obtained, and Employee #4 listened to the resident's lungs. She commented he was not moving much air. The stool was tested and found to be positive for blood. Employee #4 asked Employee #16 to contact the physician to transfer the resident to the hospital. The resident was returned to bed. It was noted the back of his pants, and the posterior-medial aspect of his pants were saturated. As the nursing assistants removed his pants and incontinence brief, it was found he had passed loose bloody stool. When they turned him to his left side to provide care, more bloody liquid was expelled. This occurred again when he was turned to his right side. At 7:10 p.m., Employee #4 was asked about the resident's blood pressure. This was thirty (30) minutes after staff had become aware of the resident's condition. She was advised it had not been checked, and she immediately went to obtain a blood pressure cuff. At 7:20 p.m., the RN went to the resident's room to start intravenous fluids in preparation for his transfer to the hospital Review of the resident's medical record, on the morning of 04/14/11, found a ""Nursing Transfer / Discharge Summary"" form had been completed. The form noted he was having profuse rectal bleeding with positive hemoccult. His pulse was noted to have been 65 and his blood pressure 90/50. The form included a section ""admitting [DIAGNOSES REDACTED]."" The section had been signed at 1:20 a.m. by Employee #14 (an LPN). -- b) Resident #26 Review of the resident's medical record, on 04/15/11, found she had orders for a 1200 cc fluid restriction. Further investigation found there was inconsistent recordation of her intakes. When staff were asked about where her intakes were tracked, they said they would be on the appetite records and the hydration records. An effort was made to determine her daily intakes. Two LPNs (Employees #15 and #21) pulled the available records for a two (2) week period. The following results were obtained: Date - Brkfst - Lunch - Dinner - 10 a.m. - 2 p.m. - 4 p.m. - 8 p.m. 04/14/11 - 480 - 480 - 480 - 120 - snack - 0 - 120 (total 1,680) 04/13/11 - NPO - NPO - 480 - R - R - R - 120 04/12/11 - 240 - 180 - 120 - 240 - blank - blank - blank 04/11/11 - 480 - LOA - 240 - blank - 240 - 240 - R 04/10/11 - 360 - 360 - 240 - 120 - snack - 120 - R (total 1,200) 04/09/11 - 480 - 240 - 120 - sleep - 120 - R - snack 04/08/11 - missed getting the forms for this date 04/07/11 - 360 - 240 - 0 (There were two (2) sheets for the same date with different amounts recorded.) 04/06/11 - 480 - NPO - 480 - 120 - R - R - R 04/05/11 - 720 - 120 - 120 - LOA - 120 - R - R 04/04/11 - 360 - 240 - 240 - blank - 240 - 240 - blank 04/03/11 - 480 - 480 - 240 - blank - 240 - 240 - blank (total 1,440) 04/02/11 - 480 - 480 - 120 - 240 - 240 - blank - blank (total 1,680) 04/01/11 - 480 - 480 - 480 - 120 - R - R - snack (total 1,560) This information was collected from the appetite sheets, the hydration sheets, and the nursing assistant sheets. The LPN who took care of filing the appetite and hydration sheets (Employee #21) and the unit nurse (Employee #15) said they did not use intake and output sheets. It was also learned the information was not recorded in the individual's medical record. This did not allow for chronicling the resident's intakes in order to determine whether the fluid restriction was being implemented as ordered. At the time of the exit conference at approximately 3:30 p.m. on 04/15/11, the director of nursing stated they had initiated using an intake sheet that had been used in the past. -- c) Resident #9 Observations, at lunch time (12:28 p.m.) on 04/14/11, found the resident lying in bed. His lunch tray sat on the overbed table which had been placed across the bed. The head of his bed had been elevated to approximately 50 degrees, and he had slid down in the bed. This resulted in his lunch tray being slightly above the height of his mouth. When asked if he could see what was on his tray, he said, ""Not really."" This resident had experienced weight losses in the recent pass, although he had gained weight in the last two (2) months. He had also had declines in his activities of daily living in the last six (6) months. The positioning of the resident for his meal did not facilitate the ease in which he could feed himself. -- d) Residents #47, #32, #9, #6, #26, and #50 Review of residents' medical records found physician's orders [REDACTED]. Review of the treatment records found the amount of the supplements ingested were not consistently recorded for six (6) of six (6) residents whose records were reviewed. This information would be needed to ascertain the individual resident's acceptance and the effectiveness of the ordered supplement. During mid-morning on 04/15/11, the treatment records were reviewed for the period from 04/01/11 through 04/14/11. The following were noted: 1. Resident #47 - An order had been written on 07/06/10 for ""Glucerna Shake 8 oz at lunch & dinner; Record % consumed."" The record showed the percentage of intake had not been recorded seventeen (17) of twenty-eight (28) times the supplement should have been provided. 2. Resident #32 - The treatment record included places to record the percentage of snacks consumed. The snacks were to be given twice a day. The order was implemented on 3-11 shift on 04/07/11 and 100% had been recorded at that time. The next fourteen (14) times the percentage should have been recorded had been omitted. This resident had experienced a significant weight loss. On 04/14/11, super cereal at breakfast had been ordered. 3. Resident #50 - On 02/28/11, [MEDICATION NAME] 8 ounces had been ordered to be given at 1000 (10:00 a.m.) and 1400 (2:00 p.m.). The order included to record the percentage consumed. From 04/01/11 through 04/14/11, this supplement should have been provided twenty-eight (28) times. The supplement was initialed as given seven (7) times. The percentage of intake was not recorded twenty-three (23) of twenty-eight (28) times it should have been recorded. This resident had experienced gradual progressive weight loss. 4. Resident #26 - This resident was also on a fluid restriction of 1200 cc / day. Her treatment record reflected an order, dated 03/31/11, for recording the percentage of her intake of Ensure 240 cc with each meal. Of the forty-two (42) times the Ensure should have been recorded, there were twenty-seven (27) omissions. The resident's weight had been recorded as 145 pounds in March 2011 and as 134.5 pounds in April 2011. 5. Resident #6 - This resident was to have the percentage of intake of Two-Cal HN recorded three (3) times a day. It was not recorded thirty-two (32) of forty-two (42) times it should have been recorded. 6. Resident #9 - On 03/08/11, an order had been written for Glucerna Shakes 8 oz to be given at 1000 (10:00 a.m.), 1400 (2:00 p.m.), and 2100 (9:00 p.m.) with the percentage of the supplement consumed. The percentage consumed was not recorded twenty-two (22) of forty-two (42) times. In a conversation with the registered dietitian on 04/15/11 at approximately 12:50 p.m., she agreed the residents' consumption of the nutritional supplements was needed when attempting to evaluate their effectiveness as weight loss interventions. .",2014-08-01
11143,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-04-05,280,D,1,0,Z4J411,". Based on resident interview, record review, and staff interview, the facility failed to revise the care plan for one (1) of fifteen (15) sampled residents when a change was made in the resident's treatment. Structured visitation by Resident #85 with her brother (Resident #37) was implemented on 02/14/11, but Resident #85's care plan was not updated to reflect this change until 04/04/11. Resident identifier: #85. Facility census: 92. Findings include: a) Resident #85 During an interview with Resident #85 on 04/04/11 at 2:00 p.m., she stated, ""They won't let me go see my brother who is on the next floor."" She further stated, ""They told me I interfere with his care, but I just dust his room because they don't."" She said she took care of her brother for twenty-three years (23) prior to him coming to the facility. The interdisciplinary team held a meeting with Resident #85 on 02/14/11, outlining the details of a new visitation schedule with her brother and limiting her to visits twice weekly. Staff would bring her brother (Resident #37) to her (Resident #85) if Resident #37 agrees to the visits. Record review revealed a care plan addressing behaviors was initiated for Resident #85 on 04/23/10. One (1) of the interventions listed on the care plan was: ""Reassure resident that she can visit w/her (with her) brother who resides on (unit number) anytime she wishes when her brother is not receiving nursing care / tx (treatment)."" Resident #85's care plan was not revised to address the structured visitation until 04/04/11. Interview with the social worker (Employee #102), on 04/05/11 at 3:00 p.m., confirmed Resident #85's care plan had not been updated to reflect the new visitation schedule until 04/04/11, even though the visitation schedule went into effect in February 2011. .",2014-08-01
11144,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-04-05,428,F,1,0,Z4J411,". Based on medical record review and staff interview, the facility failed to ensure the consultant pharmacist completed monthly medication regimen reviews for all residents in February 2011. This deficient practice affected all residents residing at the facility. Resident identifiers: #25, #80, #37, #15, and #35. Facility census: 92. Findings include: a) Residents #25, #80, #37, #15 and #35 Medical record review for the above five (5) sampled residents revealed the consultant pharmacist had not reviewed their medication regimens during the month of February 2011. During an interview on 04/05/11 at 3:00 p.m., the director of nursing confirmed the pharmacist had not visited the facility or reviewed the medication regimen of any resident in February 2011.",2014-08-01
11145,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,225,E,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure three (3) incidents of resident-to-resident altercations (involving four (4) residents) which required physician intervention were immediately reported to the State survey and certification agency in accordance with the Abuse Reporting Memorandum issued by the State survey agency to all nursing facilities in 2001. Resident identifiers: #51, #8, #17, and #43. Findings include: a) Resident #8 An interview with Resident #8, during tour on 08/10/09, found the resident had a fading bruise that extended from the top of the right arm to below the elbow. When asked how the injury occurred, Resident #8, who was alert and oriented, related that Resident #51 tried to force her way into Resident #8's room, and she put her cane against the partially opened door to stop Resident #51 from entering. Resident #51 then forced her way into Resident #8's room and took the cane from Resident #8, striking her in the head, arm, and leg. Resident #8 stated the bruise on the arm was a result of this incident. A review of incident / accident reports found this incident occurred on 07/27/09, but the bruise on the resident's arm was not reported by the resident to staff until 08/05/09. Resident #8 was seen by the physician on 08/06/09, who ordered x-rays of her arm and wrist. There were no fractures. Resident #51 was transferred to the hospital on [DATE], the day after Resident #8 reported the bruise to nursing staff. A 07/27/09 nursing note stated Resident #51 came into Resident #8's room, grabbed Resident #8's cane and hit her on the right inner knee and on the top of the head, causing her glasses to fall on the floor. No injuries were noted at that time, but the resident was upset, and one-on-one staff supervision was given. A review of the facility's abuse files found no evidence this was reported to the State survey agency. b) Resident #17 Review of the facility's incident / accident reports and nursing notes found Resident #17 and Resident #51 were involved in an altercation on 07/14/09 at 7:30 p.m., resulting in a skin tear that required steri-strips for Resident #17. A review of the facility's abuse files found no evidence this was reported to the State survey agency. c) Resident #43 Review of the facility's incident / accident reports and nursing notes found Resident #43 and Resident #51 were involved in an altercation on 07/30/09 at 2:30 p.m., when Resident Resident #51 grabbed a piece of cake from Resident #43. This altercation resulted in a skin tear for Resident #43 which required steri-strips. A review of the facility's abuse files found no evidence this was reported to the State survey agency. d) Resident #51 Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical records prior to admission (dated 04/20/09) found, ""... improved speech and walking with [MEDICATION NAME], but has become very aggressive and combative at times..."" Review of the resident's nursing notes, from 05/31/09 through 08/06/09, and the facility's incident / accident reports found numerous resident-to-resident altercations involving Resident #51, including three (3) incidents which resulted in injury to the other residents. A psychological consult, dated 08/03/09, stated, ""As per history of the last five years as given to me by family, patient has continued to deteriorate to present condition of full care and supervision, and has an extended history of combativeness and aggression as per family and nurses notes. As her present placement allows for freedom of movement, and social interaction between patients, I would recommend a more restrictive environment for the safety of patient and others."" e) Ongoing interviews with the facility's director of nursing, administrator, and social worker, on 08/11/09 and 08/12/09, failed to find evidence that these incidents were reported to the State survey agency. They indicated they were unaware these needed to be reported. f) According to the Abuse Reporting Memorandum, issued by the State survey agency in June 2001, on page 2: ""Resident to Resident and Visitor to Resident Abuse: Reporting requirements: In keeping with the Memorandum of 1994, RESIDENT TO RESIDENT and VISITOR TO RESIDENT abuse do not have to be reported to OHFLAC (the State survey agency) unless the abuse results in a need for physician intervention and/or transfer or discharge of the resident from the facility.""",2014-08-01
11146,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,203,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the transfer notice and staff interview, the facility failed to include the reason for the discharge on the written Notice of Transfer or Discharge for one (1) of thirteen (13) sampled residents (Resident #51). Facility census: 50. Findings include: a) Resident #51 Resident #51 was transferred to the hospital on [DATE]. Review of the transfer / discharge notice found in Resident #51's record disclosed no documented reason for discharge. A review of the notice was completed in the late afternoon with the social worker, and a request for additional information was made. As of exit at 7:00 p.m. on 08/12/09, no additional information was available. .",2014-08-01
11147,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,201,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to afford one (1) of thirteen (13) sampled residents, who was transferred to the hospital, an opportunity to return to the facility. Resident #51 was transferred to the hospital for evaluation due to problem behaviors on 08/06/09, and after this transfer occurred, Resident #51's family was told the facility would not re-admit the resident. Facility census: 50. Findings include: a) Resident #51 Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical records prior to admission (dated 04/20/09) found, ""... improved speech and walking with [MEDICATION NAME], but has become very aggressive and combative at times..."" Review of the resident's nursing notes, from 05/31/09 through 08/06/09, and the facility's incident / accident reports found numerous resident-to-resident altercations involving Resident #51, including three (3) incidents which resulted in injury to the other residents. A psychological consult, dated 08/03/09, stated, ""As per history of the last five years as given to me by family, patient has continued to deteriorate to present condition of full care and supervision, and has an extended history of combativeness and aggression as per family and nurses notes. As her present placement allows for freedom of movement, and social interaction between patients, I would recommend a more restrictive environment for the safety of patient and others."" A 08/06/09 physician's orders [REDACTED]."" A social service note, dated 07/24/09, stated, ""... request him (Resident #51' medical power of attorney representative - MPOA) to call next week when he gets settled and we can have a meeting to discuss what is the best plan for (Resident #51's) safety."" After requesting additional information on the late afternoon of 08/12/09, the social worker produced two (2) additional unsigned social services notes. A 08/06/09 note stated, ""... discussed resident hitting another resident last night and the aide. Advised she will be sent to (hospital) for evaluation. He agreed. Spoke with (discharge planner at hospital). Advised him that (Resident #51) cannot accept back resident do (sic) to behaviors. Referral had been made to ______."" Another unsigned note, dated 08/06/09, stated, ""... discussed the recommendations of the psychologist to have her in a more secured setting. Discussed him taking her home another facility cannot accept. He agreed to a referral be sent to ____. They can provide the secured environment that we cannot. She wanders outside the facility almost daily. She has become aggressive with other residents."" .",2014-08-01
11148,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,154,D,0,1,OCKG11,"Based on medical record review and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents was fully informed in advance of medication changes. Resident #8 was determined to possess the capacity to make her own health care decisions, but a note in the resident's medical record indicated her daughter, who was not a legally designated health care surrogate, was to be informed of medication changes before the resident was. Facility census: 50. Findings include: a) Resident #8 Resident #8 was an alert and oriented resident who had been determined by her physician to possess the capacity to understand and make her own health care decisions. Review of Resident #8's medical record found the following statement dated 02/24/09 and signed by the former director of nursing: ""Nurses: Please contact (name) before ordering new medications for (Resident #8). She would like to talk it over with her mother first. The above is not to be discussed with (Resident #8)."" A review of the statement with the current director of nursing, on 08/12/09 at 2:00 p.m., found the director of nursing was unaware of the note in the resident's medical record. .",2014-08-01
11149,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,159,B,0,1,OCKG11,"Based on a review of the resident trust account information and staff interview, the facility failed to ensure quarterly account balances / statements were being sent only to persons with the legal authority to access this information. The facility sent quarterly account balances / statements to unauthorized third parties for four (4) residents. Resident identifiers: #11, #36, #30, and #33. Facility census: 50. Findings include: a) Residents #11, #36, #30, and #33 Record review for Residents #11, #30, #33, and #36 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal fund records, with the business office manager on 08/12/09 at 10:00 a.m., found quarterly financial statements were being sent to unauthorized representatives for all four (4) residents, two (2) of whom were alert and oriented and were entitled to this information themselves. .",2014-08-01
11150,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,161,E,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a surety bond in sufficient amount to assure the security of all personal funds of residents deposited with the facility. This had the potential to affect any residents who utilized the facility to keep their personal account funds. Facility census: 50. Findings included: a) A review of information provided by the administrator, on [DATE], found the facility did not have a current surety bond to assure the security of all personal funds of residents deposited with the facility. This was verified via e-mail communication on [DATE] with the Office of Health Facility and Certification, the State agency designated as holder of surety bonds for nursing facilities. A surety bond in the amount of $2500.00 (Bond # SU,[DATE]) expired on [DATE], and it was not renewed. The total of resident funds deposited at the facility was $1474.51. On [DATE] at 5:30 p.m., the administrator reported the facility had $100,000 liability insurance, he but could not find any other information regarding this prior to exit at 7:00 p.m. on [DATE]. --- NOTE: Commercial insurance may only be used to secure resident funds when specific conditions outlined in W.V. Code are met. For example, according to W.V.C. ,[DATE]C-7, ""This insurance policy shall specifically designate the resident as the beneficiary or payee (sic) reimbursement of lost funds."" .",2014-08-01
11151,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,205,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written information regarding the facility's bed-hold policy to one (1) of thirteen (13) sampled residents, who was transferred to a hospital, to include the duration of the bed-hold policy under the State plan during which the resident would be permitted to return and resume residence in the nursing facility. Resident identifier: #51. Facility census: 50. Findings include: a) Resident #50 A review of Resident #51's closed medical record revealed Resident #51 was transferred to the hospital on [DATE]. Evidence that a copy of the facility's bed hold policy was provided to Resident #51's responsible party was not found in the medical record. On 08/12/09 at 10:00 a.m., a request for the information was made to the social worker. At exit on the evening on 08/12/09, no additional information was provided other than the social worker stating the resident was not returning to the facility, so no bed hold information was given to the resident or legal representative. .",2014-08-01
11152,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,226,E,0,1,OCKG11,"Based on a review the facility's abuse policies and staff interview, the facility failed to develop policies and procedures for immediately reporting and thoroughly investigating resident-to-resident altercations resulting in the need for physician intervention, in accordance with the Abuse Reporting Memorandum issued by the State survey agency to all nursing facilities in 2001. This had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) Residents #8, #17, #43, and #51 were involved in resident-to-resident altercations resulting in injuries requiring physician intervention. (See citation at F225.) Ongoing interviews with the facility's director of nursing, administrator, and social worker, on 08/11/09 and 08/12/09, failed to find evidence that these incidents were reported to the State survey agency. They indicated they were unaware these needed to be reported. b) A review of the facility's abuse policies failed to find evidence that policies and procedures had been developed regarding the reporting of resident-to-resident altercations that required physician intervention. c) According to the Abuse Reporting Memorandum, issued by the State survey agency in June 2001, on page 2: ""Resident to Resident and Visitor to Resident Abuse: Reporting requirements: In keeping with the Memorandum of 1994, RESIDENT TO RESIDENT and VISITOR TO RESIDENT abuse do not have to be reported to OHFLAC (the State survey agency) unless the abuse results in a need for physician intervention and/or transfer or discharge of the resident from the facility."" .",2014-08-01
11153,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,241,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that one (1) of thirteen (13) residents who was admitted to the facility on [DATE] was able be dressed and out of bed. Resident #50 Findings included: a) Resident #50 was admitted to the facility on [DATE] and was clothed in a hospital gown. Ongoing observation of the resident on 08/10/09 through 08/12/09 found the resident was dressed in a hospital gown or t-shirt without any pants on. On 08/12/09 at 10:00 a.m. the social worker was interviewed and indicated the family was supposed to bring in clothing, but had not done so yet. The social worker and the assistant activity director found clothing for the resident on 08/12/09 and the resident was able to be gotten out of bed and seated in a geri-chair in the hall way.",2014-08-01
11154,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,152,D,0,1,OCKG11,"Based on record review and staff interview, the facility allowed a resident to sign legal documents for health care decisions on the same day the resident's physician determined he did not possess the capacity to understand and make informed health care decisions and no one had been designated to serve as health care surrogate for the resident. Additionally, the physician failed to record the cause and duration of Resident #50's incapacity. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #50. Facility census: 50. Findings include: a) Resident #50 Record review revealed Resident #50 had a determination of incapacity statement signed by his attending physician at the facility. Record review also revealed that, on the same day the incapacity statement was signed by the physician, Resident #50 had signed the following documents: acknowledgment for bed rail use; acknowledgment of resident rights and privacy notice; immunization acknowledgment for declination of influenza vaccine; advance directives acknowledgment form; and permission to release information form. Interview with the social worker (Employee #8), on 08/12/09 at 2:00 p.m., revealed the resident had recently been admitted to the facility on her day off; he was accompanied by one (1) of his children. Employee #8 said, on the following day, she contacted one (1) of his children, who agreed to come in that day and speak with her, but the daughter did not appear. The next day, the physician assessed Resident #50 and determined he lacked the capacity to understand and make health care decisions. Employee #8 spoke her plans to have a yet-to-be assigned health care surrogate co-sign his legal documents, and she was in the process of making phone calls and going down the long list of family members to identify who was willing and able to serve as his health care surrogate. Interview with the social worker, on 08/12/09 at approximately 6:00 p.m., revealed she was still in the process of calling family members to determine who was able and willing to be the resident's health care surrogate, noting that it was a very large family which made the process more difficult. She explained that, prior to his admission to the facility, the transferring facility led her to believe the resident had capacity. Also at this time, it was brought to the attention of staff that the physician did not record the cause(s) of his incapacity. Employee #8 said the physician wrote the cause was ""to be determined"". Review of Resident #50's determination of incapacity form found physician documentation indicating the duration of his incapacity was ""to be determined"" (as to whether it was short term or long term), and nothing was recorded to address the cause of his incapacity. .",2014-08-01
11155,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,371,F,0,1,OCKG11,"Based on record review and staff interview, the facility failed to store, prepare, and serve foods under sanitary conditions. Dietary staff failed to routinely monitor 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. Dietary staff failed to routinely monitor the temperatures of the refrigerator, freezer, and ice cream freezer. Also, a nursing assistant failed to serve food to residents in the dining room without touching the food against her uniform. These practices had the potential to affect all residents. Facility census: 50. Findings include: a) On 08/12/09 at 2:00 p.m., review of the facility's August 2009 dishwasher temperature check log revealed places to record the 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 twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. No temperatures were measured and recorded on 08/05/09, 08/06/09, 08/07/09, 08/08/09, 08/09/09, 08/10/09, and the temperatures were recorded only once on 08/04/09. The wash and final rinse temperatures were omitted a total of nineteen (19) times each for the month of August through 2:00 p.m. on 08/10/09. The dishwasher temperatures were checked at this time and the wash cycle was at 165 degrees Fahrenheit (F) and the rinse cycle at 180 degrees F. b) The refrigerator temperature check log revealed places to record the temperature of the refrigerator three (3) times each day, for the breakfast, lunch, and dinner meals. Each of these items would have been measured and recorded twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. The refrigerator temperatures were omitted a total of seven (7) times. No temperature checks at all were measured and recorded on 08/09/09 and 08/10/09, and only temperatures were recorded once on 09/08/09. The temperature at this time was at 40 degrees F, but the dietary manager noted staff had been opening and closing the door to the unit a lot at this time. c) The freezer temperature check log revealed places to record the temperature of the freezer three (3) times each day, for the breakfast, lunch, and dinner meals. Each of these items would have been measured and recorded twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. The freezer temperatures were omitted a total of eight (8) times. No temperature checks at all were measured and recorded on 08/09/09 and 08/10/09. The temperature was recorded only once on 08/08/09 and was omitted in the evening 08/03/09. The temperature of the freezer at this time was at 0 (zero) degrees F. d) The ice cream freezer temperature check log revealed places to record the temperature of this freezer three (3) times each day, for the breakfast, lunch, and dinner meals. Each of these items would have been measured and recorded twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. The ice cream freezer temperatures were omitted a total of six (6) times. No temperature checks were measured and recorded on 08/09/09 and 08/10/09, and recordings were omitted on the evenings of 08/03/09 and 08/08/09. The temperature of the ice cream freezer at this time was about five (5) degrees below 0 (zero) Fahrenheit. During an interview with dietary manager (Employee #49) on 08/10/09 at 2:15 p.m., she acknowledged the logs had missing checks and agreed to make copies of the logs, which she did. e) On 08/11/09 during lunch tray distribution to residents in the main dining room, a nursing assistant was observed on two (2) occasions trying to hold multiple plates of bread in her hands and arms to serve to those residents and, in so doing, the sliced bread came into contact with her uniform. At this time, the dietary manager was informed of this breech in sanitary serving and offered no further information. .",2014-08-01
11007,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-05-24,282,D,1,0,BC7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation and staff interview, the facility failed to ensure treatments were provided as ordered by the physician for two (2) of eight (8) sampled residents. There was no evidence to reflect staff applied a barrier cream to the buttocks of Resident #104 after each incontinence episode, in accordance to a physician's orders [REDACTED]. Resident #112, who had an alteration in the skin integrity of her left heel and whose physician ordered that her heels be elevated when in bed, was observed on multiple occasions with her heels in direct contact with the mattress. Resident identifiers: #104 and #112. Facility census: 113. Findings include: a) Resident #104 Medical record review revealed Resident #104 was re-admitted to the facility on [DATE]. Medical information from the discharging hospital documented the resident as having ""blanchable redness to the coccyx"" upon her discharge from the hospital. Review of the admission nursing assessment dated [DATE] found, on the body diagram on page 3, no notations to indicate the presence of redness to the resident's coccyx / buttocks, and no pressure ulcer documentation form was initiated for Resident #104 on 12/18/10. Review of the physician's orders [REDACTED]."" Review of the resident's treatment administration record (TAR) revealed this treatment was not provided as ordered on any shift from 12/19/10 to 12/28/10. The director of nursing (DON), when interviewed on 05/19/11 at 12:15 p.m., was unable to provide any evidence to demonstrate this treatment was provided as directed by the resident's physician. -- b) Resident #112 Medical record review revealed Resident #112 was re-admitted to the facility on [DATE], with three (3) pressure ulcers to the coccyx and a non-pressure wound to the left heel. The wound on the left heel was documented as having an ecchymosed area measuring 2.5 cm x 1.5 cm. On 04/19/11, a physician's orders [REDACTED]."" Observation, on 05/23/11 at 9:50 a.m., found Resident #112 lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #43, a licensed practical nurse (LPN) who was passing medication on the resident's hallway, was advised of the situation and entered the resident's room. When asked if the resident's heels should be elevated, she replied, ""I do not know. I do not have the treatment book."" Employee #43 stated she would tell the treatment nurse. Observation, on 05/23/11 at 10:45 a.m., again found the resident lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #78, who was the LPN treatment nurse, was alerted by the surveyor to observe the resident. Employee #78 entered the resident's room and placed a pillow under the resident's lower legs to elevate the heels. On 05/23/11 at approximately 3:30 p.m., the DON was advised of the above findings. At that time, the DON observed Resident #112 in her room with the surveyor and found her again lying in bed with her heels in direct contact with the mattress, and with the pillow on the floor. The DON placed a pillow under the resident's legs and stated he would have to contact the physician for a new order, as the ""pillows are not working."" .",2014-09-01
11008,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-05-24,314,D,1,0,BC7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide necessary treatment and services to promote healing of pressure sores for two (2) of nine (9) sampled residents. Resident #112, who had an alteration in the skin integrity of her left heel and whose physician ordered that her heels be elevated when in bed, was observed on multiple occasions with her heels in direct contact with the mattress. For Resident #6, the treatment for [REDACTED]. and left elbows. Facility census: 113. Findings include: a) Resident #112 Medical record review revealed Resident #112 was re-admitted to the facility on [DATE], with three (3) pressure ulcers to the coccyx and a non-pressure wound to the left heel. The wound on the left heel was documented as having an ecchymosed area measuring 2.5 cm x 1.5 cm. On 04/19/11, a physician's orders [REDACTED]."" Observation, on 05/23/11 at 9:50 a.m., found Resident #112 lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #43, a licensed practical nurse (LPN) who was passing medication on the resident's hallway, was advised of the situation and entered the resident's room. When asked if the resident's heels should be elevated, she replied, ""I do not know. I do not have the treatment book."" Employee #43 stated she would tell the treatment nurse. Observation, on 05/23/11 at 10:45 a.m., again found the resident lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #78, who was the LPN treatment nurse, was alerted by the surveyor to observe the resident. Employee #78 entered the resident's room and placed a pillow under the resident's lower legs to elevate the heels. On 05/23/11 at approximately 3:30 p.m., the director of nursing (DON) was advised of the above findings. At that time, the DON observed Resident #112 in her room with the surveyor and found her again lying in bed with her heels in direct contact with the mattress, and with the pillow on the floor. The DON placed a pillow under the resident's legs and stated he would have to contact the physician for a new order, as the ""pillows are not working."" -- -- b) Resident #6 Review of Resident #6's admission nursing assessment revealed he was admitted to the facility on [DATE]. According to notations on the body diagram on page 3 of this assessment, the following wounds were present on admission: a Stage 2 pressure ulcer to the coccyx / buttocks (measuring 12 cm x 10 cm), a Stage 1 pressure ulcer (with a question mark next to it) to the left elbow (measuring 3 cm x 3 cm), and a Stage 1 pressure ulcer (with a question mark next to it) to the right elbow (measuring 7 cm x 0.5 cm). Review of the PUDFs for the wounds on the resident's right and left elbows found both were assessed as being Stage 2 pressure ulcers on 05/04/11. Both the admission nursing assessment and the entries dated 05/04/11 on the PUDFs were completed by the same registered nurse (RN - Employee #62). When re-assessed on 05/11/11, the wound on the right elbow remained at Stage 2, and the wound on the left elbow improved to Stage 1. Both wounds were resolved when re-assessed on 05/17/11. admission orders [REDACTED]. Another order directed staff to ""Keep Bilateral Elbows elevated off bed to prevent skin breakdown"". Review of the resident's care plan revealed the care plan addressed all the wounds present on the resident's admission, but the areas on the elbows were identified as Stage 1 (reddened areas), and the intervention on the care plan to treat these areas was to elevate the elbows. Review of the facility's skin treatment protocol revealed the treatment for [REDACTED]. .",2014-09-01
11009,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-05-24,279,D,1,0,BC7Z11,"**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 each resident to meet his / her medical, nursing, and mental and psychosocial needs, for one (1) of eight (8) sampled residents. Resident #6's right and left elbows were assessed as having Stage 2 pressure ulcers, but the resident's care plan did not include the treatment for [REDACTED]. Resident identifier: #6. Facility census: 113. Findings include: a) Resident #6 Review of Resident #6's admission nursing assessment revealed he was admitted to the facility on [DATE]. According to notations on the body diagram on page 3 of this assessment, the following wounds were present on admission: a Stage 2 pressure ulcer to the coccyx / buttocks (measuring 12 cm x 10 cm), a Stage 1 pressure ulcer (with a question mark next to it) to the left elbow (measuring 3 cm x 3 cm), and a Stage 1 pressure ulcer (with a question mark next to it) to the right elbow (measuring 7 cm x 0.5 cm). Review of the pressure ulcer documentation forms (PUDFs) for the wounds on the resident's right and left elbows found both were assessed as being Stage 2 pressure ulcers on 05/04/11. Both the admission nursing assessment and the entries dated 05/04/11 on the PUDFs were completed by the same registered nurse (RN - Employee #62). When re-assessed on 05/11/11, the wound on the right elbow remained at Stage 2, and the wound on the left elbow improved to Stage 1. Both wounds were resolved when re-assessed on 05/17/11. admission orders [REDACTED]. Another order directed staff to ""Keep Bilateral Elbows elevated off bed to prevent skin breakdown"". Review of the resident's care plan revealed the care plan addressed all the wounds present on the resident's admission, but the areas on the elbows were identified as Stage 1 (reddened areas), and the intervention on the care plan to treat these areas was to elevate the elbows. Review of the facility's skin treatment protocol revealed the treatment for [REDACTED]. .",2014-09-01
11010,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,241,E,0,1,2I6B11,"Based on observation and staff interview, the facility failed to promote care for residents in a manner that maintained each resident's dignity. During observations in the main dining room, observation found all residents were not served a pre-meal salad, and residents seated at the same table were not served their salads at the same time. This practice had the potential to affect all residents who took their meals in the main dining room and were on mechanically altered diets. Facility census: 187. Findings include: a) Observations in the main dining room, on 10/13/09, at 12:15 p.m., found the kitchen staff was passing out pre-meal salads. Not all residents who ate at the same tables were served salads, and some residents seated together received their salad after others had already consumed theirs. In an interview on 10/14/09 at 3:30 p.m., the facility's dietician (Employee #9) revealed, on days salads were on the menu, residents with orders for regular consistency diets received salads, and residents with orders for mechanically altered diets were not served salads. The dietitian confirmed that residents on mechanically altered diets were not offered a substitute for the salads while others ate. The dietician also confirmed that some residents, who were on regular diets and could have salads, were not served their salads in a timely manner (so that residents seated together could eat together). .",2014-09-01
11011,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,224,D,0,1,2I6B11,"Based on record review and staff interview, the facility failed to immediately report to the State survey and certification agency an allegation of misappropriation of resident property for one (1) of twenty-six (26) residents reviewed. Resident identifier: #10. Facility census: 187. Findings include: a) Resident #10 The medical record of Resident #10, when reviewed on 10/14/09, disclosed (in a nurse's note dated 09/02/09) a family member of this resident reported some missing jewelry from the resident's room to include a pair of earrings, two (2) gold rings, and a silver watch. The note further stated the facility's director of nurses and a social worker were made aware of this allegation shortly thereafter. Review of facility's documentation of allegations of abuse, neglect, and misappropriation of resident property that had been reported to the State agency within the past year disclosed no mention of this allegation. The social worker involved in this incident (Employee #58), when interviewed on 10/15/09 at 9:00 a.m., stated she was working with the family in an attempt to reimburse them for the loss, but she confirmed the allegation had not been reported as mandated by this regulation. .",2014-09-01
11012,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,505,D,0,1,2I6B11,"Based on record review and staff interviews, the facility failed to promptly notify the physician of all lab results, ensuring that appropriate action be taken if indicated in a timely manner for three (3) of twenty-six (26) sampled residents. This practice has the potential to affect any resident who had lab work and whose physician was notified only via fax machine. Resident identifiers: #98, #185, and #74. Facility census: 187. Findings include: a) Residents #98 and #185 1. Resident #98 A review of the medical record revealed laboratory reports of cultures from blood and wound exudate collected on 06/27/09 and a comprehensive metabolic panel from blood also drawn on that same date. The panel included seven (7) abnormal values. There was no evidence on the reports, in the nurses' notes, in the physician's progress notes, or elsewhere in the chart that the attending physician received and reviewed the results. 2. Resident #185 A review of the medical record revealed laboratory reports for blood drawn on 08/17/09, but there was no evidence on the report, except for a stamp stating that it had been faxed, or in the physician's progress notes, or nurses notes that indicated that the physician had received and/or reviewed the results. 3. During an interview with the director of nursing (DON) and a nurse consultant (Employee #211) at 9:00 a.m. on 10/14/09, they acknowledged that some of the physicians did not initial or sign the lab reports during their required visits, but they were surprised that the nurses' notes did not indicate the physician had received the reports. The nurse consultant stated she was satisfied that the faxed reports reached the physician's office and had no knowledge of any negative outcomes that could be traced back to a lack of timely action on abnormal labs. Both did admit there was no way to prove, through the present documentation, that the physician received the reports. b) Resident #74 The medical record of Resident #74, when reviewed on 10/13/09, disclosed this resident had undergone lab testing (a basic metabolic panel) as ordered by her physician on 07/28/09 and again on 10/05/09. On both occasions, the results reported from these lab tests had abnormal findings. The resident's levels were outside the determined normal levels by the testing lab. The result documents were stamped as ""faxed"" with a date. This ""faxed"" designation did not detail to whom the results were faxed or provide evidence that the faxed results were ever received by the intended recipient, presumably their physician. The DON, when interviewed on 10/13/09 at 3:45 p.m. concerning this finding, explained this ""faxed"" stamp indicated the abnormal results had been faxed to the office of the resident's attending physician. The DON further confirmed this was no indication that the physician had indeed seen the abnormal reports. The DON also acknowledged the facility had no formal method of assuring the physicians had actually seen or been made aware of the faxed abnormal lab results.",2014-09-01
11013,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,279,E,0,1,2I6B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive care plans for five (5) of twenty-six (26) sampled residents. Two (2) residents with pain and three(3) residents prescribed psychoactive medications did not have a care plan developed to include these areas. Resident identifiers: #103, #129, #176, #185, and #82. Facility census: 187. Findings include: a) Resident #103 Resident #103's medical record, when reviewed on 10/13/09 at 11:15 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident had a current [DIAGNOSES REDACTED]. The minimum data set (MDS), with an assessment reference date (ARD) of 09/13/09, indicated the resident had pain daily during the review period. The care plan, dated 09/22/09, failed to address the resident's pain. The care plan nurse (Employee #89), when interviewed on 10/14/09 at 12:40 p.m., did not provide any additional evidence to reflect pain management was addressed on the resident's current care plan. b) Resident #129 Resident #129's medical record, when reviewed on 10/13/09 at 10:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident had a current [DIAGNOSES REDACTED]. The care plan, dated 09/08/09 failed to address the resident's pain. Employee #89, when interviewed on 10/14/09 at 12:40 p.m., did not provide any additional evidence to reflect pain management was addressed on the resident's current care plan. c) Resident #176 A review of Resident #176's medical record revealed she had been receiving [MEDICATION NAME] 50 mg twice a day and 100 mg at bedtime daily to treat [MEDICAL CONDITION] since 06/17/04. She had also been receiving [MEDICATION NAME] 37.5 mg twice daily since 07/22/08 for the treatment of [REDACTED]. The 01/11/09 significant change in status MDS indicated these classifications of medications were being given; in Section V, the resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use triggered for further review, and the interdisciplinary team noted this problem area would be addressed in the care plan. A review of the RAP documentation revealed the facility was aware of the potential for drug-related physical / cognitive / behavioral impairment, and the assessor again indicated the interdisciplinary team decided to ""proceed"" with addressing this problem area on the care plan. A review of the resident's care plan (last revised on 09/08/09) found no mention of the problem of [MEDICAL CONDITION] drug use; no goal had been set, and there were no nursing interventions to address the need to monitor for effectiveness as well as potential adverse side effects associated with the use of these psychoactive drugs. The only reference in the entire care plan related to [MEDICAL CONDITION] medication was a sentence stating, ""Observe for side effects of [MEDICAL CONDITION] meds."" There was no measurable goal. There was no evidence in the record (e.g., nurses' notes, medication administration record) that the resident was being monitored or that any side effects have been observed, although the physician stated, in a progress note dated 08/13/09, the resident had increased urinary incontinence, a slight involuntary tongue intrusion, and psychomotor [MEDICAL CONDITION]. During an interview with the director of nursing (DON) and the nurse consultant (Employee #211) at 9:00 a.m. on 10/14/09, they agreed, after reviewing the record, there was no description of the services necessary to assure the resident was monitored in order to achieve maximum benefits from [MEDICAL CONDITION] medications with a minimum of adverse side effects. d) Resident #185 A review of Resident #185's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had been receiving [MEDICATION NAME] 10 mg twice daily for anxiety and [MEDICATION NAME] 15 mg every night for depression since 12/30/08. The use of both of these classifications of medications was noted on the most recent comprehensive MDS which triggered the RAP for [MEDICAL CONDITION] drug use, and the interdisciplinary team noted this problem area would be addressed in the care plan. A review of the care plan (last reviewed and revised on 08/25/09) found not problem, measurable goals, or nursing interventions addressing the use of these medications. The care plan contained only one (1) reference to these medications under the problem, ""Thought Process, Alteration In"", which stated, ""...receives antidepressant and antianxiety medications."" During an interview with the registered nurse (Employee #194) at 3:40 p.m. on 10/14/09, she was asked to review the care plan and locate the plan for [MEDICAL CONDITION] drugs, but she could not. e) Resident #82 A review of Resident #82's medical record revealed he had been receiving [MEDICATION NAME] daily for depression for an extended period of time. His annual MDS, dated [DATE], triggered the RAP for [MEDICAL CONDITION] drug use. The RAP documentation indicated the resident exhibited an ""unsteady gait"" and had fallen in the past thirty-one (31) to one hundred eighty (180) days, and it listed six (6) adverse side effects for staff to observe for; the interdisciplinary team noted this problem area would be addressed in the care plan. A review of the care plan (last reviewed and revised on 08/11/09) found ""[MEDICAL CONDITION] med use"" mentioned in association with the problem of ""Alteration in Thought Processes"", and one (1) of the nursing interventions was: ""Observe for side effects of [MEDICAL CONDITION] meds."" However, the use of [MEDICAL CONDITION] medications was not identified as a problem, no measurable goals were formulated, and there were no nursing interventions planned to reach a goal of maintaining this resident to his maximum health care status while on this medication. During an interview with the director of nursing (DON) and the nurse consultant (Employee #211) at 9:00 a.m. on 10/14/09, they agreed, after reviewing the record, there was no description of the services necessary to assure the resident was monitored in order to achieve maximum benefits from [MEDICAL CONDITION] medications with a minimum of adverse side effects. .",2014-09-01
11014,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,157,D,0,1,2I6B11,"Based on medical record review and staff interview, the facility failed to immediately notify the physician when Resident #171's right arm and elbow were noted to be red and warm with extensive inflammation. Resident identifier: #171. Facility census: 187. Findings include: a) Resident #171 Medical record review,on 10/13/09, found a nursing note, dated 08/18/09 at 2130 (9:30 p.m.), stating the resident was noted to have redness and warmth on the right arm and elbow, and the resident's medical power of attorney was notified at that time of extensive inflammation. A subsequent nursing note, dated 08/19/09 at 0715 (7:15 a.m.), revealed, ""Rt (right) elbow has skin tear which is scabbed no drainage. Surrounding skin very swollen pink and warm from mid forearm posterior to above elbow."" The nurse also indicated a fax was sent to the physician and a new order for antibiotic therapy was received at 0800 (8:00 a.m.). During an interview on 10/14/09 at 4:30 p.m., the director of nursing (Employee #136) confirmed the physician was not immediately informed of the extensive inflammation to the resident's right arm when this change in condition was first noted at 9:30 p.m. on 08/18/09. .",2014-09-01
11015,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,274,D,0,1,53ZE11,"Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to recognize a significant change and complete a comprehensive resident assessment for two (2) of twenty one (21) sampled residents. Resident identifiers: #84 and #92. Facility census: 121. Findings include: a) Resident #84 On 02/03/09 and 02/04/09, review of the resident's comprehensive admission MDS, with an assessment reference date (ARD) of 07/25/08, found the assessor indicated (in Section G1, subsections b, c, d, and e) that resident was independent in the following activities of daily living (ADLs): transfer, walking, and locomotion. In addition, assessor indicated the resident needed supervision and set-up help only for dressing (section G1g) and set-up help only for eating (section G1h). The resident was independent in toilet use (section G1i) and continent of bowel and bladder (sections H1a and b). Review of the resident's abbreviated quarterly MDS assessment, with an ARD of 10/26/08, revealed the assessor indicated the resident was now totally dependent for transfer and required the physical assistance of one (1) person to walk in his room. In addition, the assessor indicated the resident was totally dependent for dressing and feeding, requiring one (1) person to physically assist, and the resident was incontinent of bowel and bladder and totally dependent for toilet use. A comprehensive assessment was not conducted to address the significant decline in multiple ADLs that occurred to this resident over the preceding three (3) months. On 02/05/09 at 9:25 a.m., the MDS nurse (Employee #148) provided a quarterly MDS assessment, with an ARD of 01/18/09, which showed the significant changes had not resolved. The MDS nurse was interviewed at that time about the significant change. After reviewing the issue, she verified she ""could see where there could have been significant change (comprehensive) assessment."" b) Resident #92 A review of the medical record revealed the facility had failed to determine there had been a significant change in the resident's physical condition. The comprehensive admission MDS, with an ARD of 07/29/08, indicated the resident exhibited a sad mood up to five (5) days a week; was totally dependent upon staff for transferring and eating; did not ambulate in the previous seven (7) days; was totally incontinent of bowel; and exhibited moderate pain less than daily. In the abbreviated quarterly MDS, with an ARD of 10/26/08, the resident exhibited NO moods; had improved to requiring extensive assistance for transfers and ambulation; was now independent after set-up for eating; had a significant weight loss of nine (9) pounds, and had NO bowel incontinence or pain. When these changes were discussed with the MDS nurse (Employee #171) at 4:15 p.m. on 02/04/09, she stated that all the assessments were correct, but the computer had not registered this as a significant change in status. .",2014-09-01
11016,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,514,B,0,1,53ZE11,"**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 clinical records for two (2) of twenty one (21) sampled residents. Resident identifiers: #53 and #92. Facility census: 121. Findings include: a) Resident #53 Record review, on 02/04/09, revealed a doctor's progress note indicating the resident lacked the capacity to make healthcare decisions. This progress note contained no date and time. A social worker (Employee #79) provided a copy of the doctor's progress note at 2:50 p.m. on 02/04/09. The social worker was interviewed at this time, reviewed the record, and verified the note contained no date and time. b) Resident #92 A review of the medical record revealed a social services progress note, dated 10/22/08, which contained the following: ""Resident is a full-code status per POST."" Review of the Physician order [REDACTED]. These additional limitations would be contrary to a ""Full Code"". During an interview with the two (2) social workers (Employees #79 and #119) at 11:45 a.m. on 02/04/09, they reviewed the record and agreed that ""Full Code"" was an error in their notes. .",2014-09-01
11017,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,165,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to address grievances in a timely manner. Resident #109 had resided in the facility for over seven (7) years, and the facility failed to adequately address his repeated requests to have a cool sleeping environment at night. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #109. Facility census: 121. Findings include: a) Resident #109 Record review revealed Resident #109 was an alert, oriented [AGE] year old male who resided in the facility for nearly eight (8) years. His physician had determined he had the capacity to understand and make his own informed healthcare decisions. Due to [DIAGNOSES REDACTED], he required total assistance from staff with the performance of activities of daily living. He was unable to leave his bed unless lifted out with a mechanical or other total lift, was unable to walk, and used a motorized wheelchair. During an interview on 02/04/09 at approximately 10:00 a.m., he stated his desire to keep his room warm by day and cool at night. Per the resident, he gets up in his scooter by day and feels cold. At night, he likes to cover up in bed with his warm blanket to keep his trunk and extremities warm, but he needs to have cooler air during sleep to facilitate breathing, feeling like he smothers if the air is too hot. He stated staff has known of these needs for years. He stated the heat last night was so unbearable he could not breathe, but staff refused to turn down the heat as he requested. He said he awoke drenched in sweat and had to get up at 2:30 a.m. to sit in his scooter for the remainder of the night, so he could breathe. He said he would like to have his room at 66 degrees Fahrenheit (F) while sleeping at night, although this was an estimated number as there was no thermometer in the room to measure the exact temperature. He was considering moving to another facility, but he stated his preference would be to stay where he was, since this was his home, if only the heat could be turned down at night. Interview with a social worker (Employee #119), on 02/04/09 at 2:15 p.m., revealed she was aware of his desire for coolness at night during sleep, and she admitted this had been an ongoing problem resulting in numerous roommate changes over the years. She said his current roommate, who had dementia, was placed there in the past week or so, and he was unable to speak for himself and say if he felt warm or cold. Interview with Resident #109's former roommate (Resident #9), on 02/04/09 at 2:45 p.m., revealed Resident #9 (aged 95) recently moved out of that room because it was too cold at night. He transferred to another room down the hall but, due to the television being too loud, he transferred again to the private room where he currently resides. At this time, Resident #9 was fully dressed and wore a heavy jacket over his street clothes and his room felt very warm, yet he stated he just felt comfortable at the moment. This resident had resided in the facility since 01/23/09. An attempt was made to interview Resident #109's current roommate on 02/04/09 a 3:15 p.m., but he was not interviewable due to his [DIAGNOSES REDACTED]. Interview with the assistant director of nursing (Employee #65), on 02/04/09 at approximately 3:00 p.m., revealed she, too, was aware of his desire for a cool room at night. She stated the water pipes in that room froze once about a year ago. She agreed the resident's stated desire for a 66 degree F temperature at night was not too cold for her, but there was no thermometer to objectively gauge the actual room temperature. She reported that, once, a nurse arrived to work at 7:00 a.m. and said she could see her breath in that room. Resident #109's unresolved desire for a cool sleeping environment was relayed to the administrator, the director of nursing, and other staff present on 02/04/09 at approximately 4:00 p.m., and they acknowledged this has been a recurring problem throughout the years trying to suit him with compatible roommates. On 02/05/09 at 8:45 a.m., the social worker (Employee #119) reported the facility obtained a thermometer for the resident's room and planned to keep the room between 72 degrees F and 81 degrees F, and she asked if the State regulation stipulated a room temperature between these two (2) parameters, as there was a roommate to consider who could not speak for himself. She stated that to her knowledge there had never been a thermometer in his room before. When asked if the facility was abiding by Resident #109's wishes for his comfort zone (citing his comfort as the right temperature for him), and about the facility's inability to find a suitable roommate in the seven (7) years Resident #109 had resided there, Employee #119 offered no further information at this time. On 02/05/09 at 9:45 a.m., observation found Resident #109 lying in his bed. When interviewed, he reported feeling ""completely beat"" due to two (2) nights in a row without good sleep due to the heat. He stated, ""I woke up and couldn't get my breath and was wringing wet."" He stated the nurse told him, at 3:00 a.m., that it was 78 degrees F and informed him the room temperature had to be at least 72 degrees F and she would not lower the heat for him. Review of nursing notes, dated 02/05/09 at 3:00 a.m., found, ""Heat on set @ (at) 78 degrees per thermometer in room."" A subsequent note, at 5:00 a.m., recorded the room temperature at 74 degrees, documented his complaint of sweating and not breathing well due to the heat, and documented verbal exchanges for the preceding twenty (20) minutes that acknowledged ""he is miserable"" but contained no documentation of comfort measures nor reassurances being offered. Clinical record review revealed a social services progress note, dated 01/29/09, documenting Resident #109 being upset about the food and reporting he could move to another facility, followed by staff advisement ""that we only wanted to keep both he and his roommate comfortable"". Another social services progress note, dated 02/03/09, documented a meeting with Resident #109, during which the author ""completed an assessment for possible transfer. . . . (Resident) has been unhappy with HOK (Heartland of Keyser) regarding room temperatures"". The note further indicated a plan to contact another facility when a bed becomes available. .",2014-09-01
11018,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,279,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a plan of care to address a change in a resident's psychosocial well-being, and failed to plan non-pharmacologic interventions to address a resident's problem of anxiety with bathing prior to initiating psychoactive medications. Resident identifier: #94. Facility census: 121. Findings include: a) Resident #94 Record review revealed Resident #94 was an [AGE] year old female with [DIAGNOSES REDACTED]. Additionally, she suffered a fall in the facility October 2008 and sustained a fractured ankle requiring surgical repair. Further record review revealed a nursing note, dated 12/29/08 at noon, describing Resident #94's anxiety with bathing as evidenced by behaviors of ""yelling / screaming combative c/ (with) CNA's (certified nursing assistants) splashing bath water all over floor as well as CNA . . . hitting / hurting CNA."" These behaviors were significant enough at this time for the nurse to notify the physician for ""possible Rx (prescription) d/t (due to) anxiety with bath"". On 12/30/08, the physician ordered anti-anxiety medication [MEDICATION NAME] 0.25 mg orally in the mornings on bath days Mondays and Fridays for a [DIAGNOSES REDACTED]. The resident had been on skilled care due to the fractured ankle, but nursing notes dated 01/13/09 documented that, on 01/12/09, she was skilled for wound dressing changes and for ""mood and behaviors"". A nursing note dated 01/19/09 cited the resident was still combative during bath time and ""difficult to give care to"", again necessitating physician notification on this date. Subsequently, injectable [MEDICATION NAME] 5 mg was ordered by the physician on 01/20/09, to be given an hour before bath time on Mondays and Fridays, instead of the [MEDICATION NAME] for increased agitation and anxiety. A minimum data set (MDS) assessment, with an assessment reference date of 01/13/09, cited behaviors and moods present under the corresponding subsets. However, there was no identification of the problem of anxiety during bathing on the resident's current care plan, nor were there goals to decrease the resident's behaviors or moods, nor interventions to address the bathing-related anxiety through non-pharmacologic measures. Review of all nursing notes from 12/15/08 through 02/03/09 revealed no documentation of any interventions addressing the bathing-related anxiety other than using psychoactive medications on bathing days. Throughout this time frame, there was only one notation of agitation at times other than bathing, which occurred at 5:30 p.m. on 01/22/09. On 02/04/09 at 9:00 a.m., a nursing assistant who provides whirlpool baths, when interviewed, reported Resident #94 has been resisting the bath for the past couple of months. At 9:15 a.m. on 02/04/09, a nurse (Employee #82) reported during interview her belief that the [MEDICATION NAME] (which was initiated on 12/30/08) did not help with the resident's combativeness at bath time, but the [MEDICATION NAME] seemed to help. The findings of medicating with [MEDICATION NAME] and [MEDICATION NAME] on bath days in the absence of identified problems and interventions on the current care plan was reported to the director of nursing and administrator the afternoon of 02/04/09. Several nursing assistants were also interviewed the morning of 02/05/09, and all agreed the resident was combative during bathing times, with one (1) noting they had even tried bathing her at different times of the day without success. .",2014-09-01
11019,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,371,F,0,1,53ZE11,"Based on observation and staff interview, the facility failed to ensure foods were stored and served under sanitary conditions, as evidenced by the absence of a thermometer in the kitchen's reach-in refrigerator, to allow monitoring of temperatures stored in this refrigerator. This practice had the potential to affect all residents in the facility who received nourishment from the facility's kitchen. Facility census: 121. Findings include: a) During service of the evening meal on 02/02/09 at 5:00 p.m., observation found dietary staff obtaining 8 oz cartons of milk from the kitchen's reach-in refrigerator and placing the milk cartons onto the residents' dining trays for the evening meal. No thermometer was visible in this refrigerator located beside the serving line, in which were stored numerous plastic crates containing cartons of milk. With no thermometer to measure the internal temperature of this storage area, it could not be assured that all the milk products were stored under proper temperatures. The assistant food service director (Employee #132) removed all crates from inside this refrigerator but was unable to locate a thermometer inside at this time. He agreed that each refrigerator and freezer in the dietary department should have a thermometer, and he reported this reach-in refrigerator generally had one, too. Subsequently, he located a thermometer and placed it inside the kitchen refrigerator. .",2014-09-01
11020,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,164,D,0,1,53ZE11,"Based on an observation and staff interview, the facility did not ensure one (1) resident of random selection (#120) was afforded the right to confidentiality of clinical records. Facility census: 121. Findings include: a) Resident #120 An observation, on 02/03/09 at 9:25 a.m., revealed Resident #120's Medication Administration Record [REDACTED]. The medication cart was in the hallway and visible to anyone walking in the area. An interview with the nurse (Employee #139) revealed she forgot to close the medication binder after she dispensed the prescribed medications and walked into the room to administer the medications to the resident. .",2014-09-01
11021,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,152,D,0,1,53ZE11,"Based on record review and staff interview, the facility failed to assure a resident, who had been determined to lack the capacity to understand and make informed healthcare decisions, had his decisions made by a legal surrogate designated in accordance with State law. The facility had Resident #92 sign an informed consent form authorizing the administration of the influenza vaccine, even though he had been determined to lack the capacity to make such healthcare decisions. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 Medical record review revealed the attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on 07/28/08. This determination was validated by a second determination made by a psychologist on 08/01/08. Further record review revealed Resident #92 had signed an informed consent form authorizing the administration of the influenza vaccine on 10/22/08. No other signature was on the form. During an interview with the social worker at 11:45 a.m. on 02/04/09, she acknowledged, after reviewing the chart, that Resident #92 should not have been asked to sign this form, as the resident did not have the capacity to understand and make healthcare decisions at that time. (Note: After the fact, on 11/19/08, the resident's attending physician reversed this and determined the resident had the capacity to formulate healthcare decisions. However, at the time the resident signed the vaccination consent form, he did not.) .",2014-09-01
11022,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,155,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and ""Limited additional interventions"". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had ""Full Code"" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: ""It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of Keyser, as I am presently in a weakened condition and do not wish to sign all of the forms necessary for admission."" The resident had several acute hospitalization s, and a social service note on [DATE] indicated his daughter was his health care surrogate and that he was still ""full-code status"". A new POST form, indicating the resident was not to be resuscitated and was to receive limited additional interventions, was signed by his wife on [DATE], while he was in the hospital. There was no evidence to show the wife had any legal authority to make healthcare decisions for him at that time. The resident was readmitted to the facility on [DATE], and all documentation indicated the resident had the capacity to form his own healthcare decisions. However, there was no evidence he had been involved in his healthcare decisions, including formulating the advance directives recorded on the POST form. In an interview with both social workers (Employees #79 and #119) at 2:40 p.m. on [DATE], they were asked if the resident was aware of his code status. Neither answered, nor was any documentation offered. They both verified the resident was alert, oriented, and able to make his needs known with sign language. .",2014-09-01
11023,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,159,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility records, and staff interview, the facility failed to notify the responsible party an incapacitated Medicaid recipient when the amount in the resident's account was within $200.00 of the SSI resource limit, for one (1) of eighty-nine (89) residents with personal trust fund accounts managed by the facility. Resident identifier: #28. Facility census: 121. Findings include: a) Resident #28 A review of the Resident #28's medical record revealed this [AGE] year old female who had been determined to lack capacity and who had previously designated her daughter to serve as both her medical and financial power of attorney. The primary payer for her nursing home stay was MCD - Medicaid (West Virginia). The resident's trust statement, dated 02/03/09, stated the balance of funds in her account was $2,590.40. The balance had reached the total of $1800.00 on 12/01/08, at which time the facility should have notified the responsible party that the resident's account was within $200.00 of the allowed SSI limit. There was no evidence in the file to indicate the resident's responsible party had been notified of the account balance and the possible repercussions of this total (loss of Medicaid eligibility), although quarterly statements had been posted in January 2009. During an interview with Employee #159, who was responsible for handling resident funds, at 2:00 p.m. on 02/04/09, she stated she was aware of the balance and explained that she supplied a list of resident balances to the business office manager (Employee #154) each month. The business office manager was to notify families of high balances. Employee #154, when interviewed at 2:15 p.m. on 02/04/09, stated he had tried to contact Resident #28's responsible party by phone but had gotten no answer. He explained the practice of the facility was to notify the family when the balance reached $1800.00, and when the total reached $2000.00, he was to notify DHHR; he stated that he had already done this. He also stated he was going to send a form to the responsible party to sign for permission for the facility to purchase something for the resident, but he was not sure what it would be, and he had not done so when asked at 11:00 a.m. on 02/05/09. The social worker (Employee #79), when interviewed at 2:30 p.m. on 02/04/09, was asked if she was aware of the resident's amount of available funds. She stated she was not, that she was usually not informed of the amounts in the resident accounts and was not involved in contacting the family, although, if asked, she could suggest items the resident might need. When told that a review of the nurses' notes revealed evidence of family notification of changes in condition, she verified the family member was very involved in her mother's care, that she had not had a problem reaching her by phone, and more than one (1) contact number was listed for the responsible party on the resident's medical record. .",2014-09-01
11024,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,280,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to evaluate and revise the care plan as the resident's status changed, for one (1) of twenty-four (24) sampled residents. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 A review of Resident #92's medical record revealed he was admitted on [DATE] after a lengthy hospitalization . His admission minimum data set (MDS) assessment indicated he was totally dependent for bed mobility, transfer, locomotion, dressing, eating, and hygiene, and there was no ambulation in the previous seven (7) days. A care plan was developed addressing these needs with appropriate goals for a severely debilitated resident. An abbreviated quarterly MDS, dated [DATE], indicated the resident required extensive assistance with bed mobility and transfer, limited assistance with ambulation and locomotion; and is now independent except for set-up with eating. However, the resident's most current care plan addressing activities of daily living (ADLs), last reviewed on 11/12/08, contained no evidence of revisions to the care plan to reflect an improvement in the resident's self-performance of ADLs. In an interview with the MDS nurse (Employee #171) at 4:00 p.m. on 02/04/09, she acknowledged, after reviewing the care plan, that it should have been revised as the resident was no longer totally dependent on others for the self-performance of ADLs. .",2014-09-01
11025,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-04-27,323,E,0,1,53ZE12,"Based on observation and staff interview, the facility failed to ensure medication carts were locked when left unattended by the nurse. This occurred for two (2) of four (4) medication carts observed during tour on 04/19/09. Facility census: 114. Findings include: a) Observations, on 04/19/09 at 9:15 p.m., found the medication cart was left unlocked by the nurse. The nurse (a registered nurse - Employee #24) was not within sight of the cart, and the corridor door to the room in which the nurse was passing medications. Upon coming out of the room, the nurse was notified the medication cart was not locked. b) Observations, on 04/19/09 at 9:30 p.m., found the medication cart was left unlocked by the nurse. The nurse (a licensed practical nurse - Employee #11) was not within sight of the cart, and the corridor door to the room in which the nurse was passing medications was closed. There were sixteen (16) vials of insulin located on the top of the medication cart in a box. .",2014-09-01
11026,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-05-06,225,E,1,0,3ZBG11,". Based on review of facility documents, facility policy review, and staff interview, the facility failed to assure two (2) of five (5) allegations of abuse / neglect and misappropriation of resident property were reported immediately to other officials, including the State survey and certification agency, in accordance with State law. The facility also failed to conduct thorough investigations related to an allegation of abuse and an allegation of misappropriation of resident property. Additionally, the facility failed to assure a registered nurse (RN - Employee #14) provided protection for one (1) facility resident (#17) who reported having been slapped in the face by a staff member. Employee #14 failed to report this allegation of abuse in accordance with facility policy and State law. Employee #14 informed the alleged perpetrator, a nursing assistant (NA - Employee #43) of the resident's allegation against her and allowed the alleged perpetrator to continue to provide care in the facility where she would have access to Resident #17 and other residents residing in the facility. The facility did not conduct a thorough investigation related to the resident's allegation that an aide had slapped her in the face. Resident identifiers: #17, #57 (former), and #58 (former). Facility census: 56. Findings include: a) Resident #17 1. Review of facility documents found a written statement saying Resident #17 approached the administrative assistant (Employee #61) on 04/29/11 at 3:00 p.m. and reported that a NA (identified as Employee #43) had slapped her in the face while she was in the bathroom. Employee #61 asked Resident #17 if the NA left marks on her face; the resident replied that ""her face feels like it was slapped."" Further review found the resident reported this allegation of abuse to the RN charge nurse (Employee #14) on the evening shift on 04/28/11. On 05/06/11 at 10:00 a.m., an interview was conducted with Employee #14 via speaker phone with the director of nursing (DON - Employee #11) present. Employee #14, when asked to relay the events surrounding the allegation voiced by Resident #17 that Employee #43 had slapped her face while in the bathroom, stated that an aide (could not identify) came to him around 6:00 p.m. and told him Resident #17 stated Employee #43 had slapped her face while in the bathroom. Employee #14 stated he went to Resident #17 and she also told him that Employee #43 had slapped her face while in the bathroom. Employee #14 then stated that he went to Employee #43 and told her that Resident #17 had accused her of slapping her in the face while in the bathroom. He stated the NA denied the allegation. Employee #14, when asked if he removed Employee #43 from duty following the resident's allegation against her, stated he did not. When asked if he reported the allegation as required or notified the DON of receipt of the allegation of abuse, he stated he did not. When was asked if he reported the allegation to the oncoming shift, he stated he was unsure if he had reported it. The facility could provide no evidence that anyone in the facility had knowledge of the resident's allegation that she was slapped in the face by Employee #14 prior to the resident's report to the administrative assistant on the following afternoon. - 2. Review of the facility's investigation related to Resident #17's allegation of being slapped in the face by Employee #43 found that a thorough investigation was not conducted. Review of the assignment sheet for the evening shift of 04/28/11 found merely statements had only been obtained from the RN charge nurse (Employee #14) and the alleged perpetrator (Employee #43). There was a licensed nurse working the evening shift and five (5) other aides from which the facility did not obtain statements to determine if they had any knowledge of the event. - 3. Review of facility policy 1.0 entitled ""WV Abuse Prohibition"", found in Section 5.1.2, the following language: ""The employee alleged to have committed the act of abuse will be removed from duty pending an investigation."" - 4. An interview with the DON, on 05/06/11 at 10:10 a.m., confirmed that Employee #14 should have immediately reported the allegation and suspended the NA pending an investigation. -- b) Resident #57 Review of facility document found a complaint, lodged by the treating physician on 09/09/10, that Resident #57 alleged an NA had taken her call light away from her the previous night. There was no evidence to reflect the facility had reported this allegation in accordance with State law. The facility did not begin an investigation until 09/15/10, when a statement was obtained from the alleged perpetrator. A second statement was obtained on 09/16/10, from the NA who worked this particular hall with the alleged perpetrator. The facility could provide no evidence that statements were obtained from other staff members working at the time of the allegation. The facility could provide no evidence this allegation was reported to other officials including the State survey and certification agency in accordance with State law. -- c) Resident #58 Review of facility documents found that, on night shift on 08/10/10, Resident #58 reported an NA who worked the morning shift had taken fifty dollars ($50) and a list of groceries from her and had not brought her supplies or her money back to her. The facility could provide no evidence this allegation of misappropriation of property was reported to officials, including the State survey and certification agency, in accordance with State law. Additionally, the facility did not conduct a thorough investigation in order to determine if an act of misappropriation had occurred. The facility did not obtain a statement from the alleged perpetrator . .",2014-09-01
11027,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-05-06,323,E,1,0,3ZBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and an evaluation of the functionality of Wanderguard devices, the facility failed to assure fourteen (14) of twenty-four (24) Wanderguard devices currently in use by residents were checked for proper functioning in accordance with physician's orders [REDACTED]. Additionally, the Wanderguard devices for two (2) of the fourteen (14) residents were not operational on the afternoon of 05/05/11. Resident identifiers: #13, #43, #15, #5, #41, #42, #53, #22, #2, #24, #28, #55, #8, and #23. Facility census: 56. Findings include: a) Resident #13 Review of the medical record found that, on 01/10/10, the treating physician ordered the resident to wear a Wanderguard bracelet to notify staff of an attempt to elope. Review of the treatment record found nursing staff did not document that this resident's Wanderguard was checked for proper functioning on the evening of 05/04/11. At 1:00 p.m. on 05/05/11, a licensed practical nurse (LPN - Employee #25) was asked to check Resident #13's Wanderguard. Employee #25 obtained a device from the medication cart and tested the resident's Wanderguard bracelet. It was found to not be functioning. Following this discovery, the treatment records were reviewed for all residents with orders for Wanderguard bracelets to warn of possible elopement. This review revealed that none of the fourteen (14) residents with orders for Wanderguard bracelets on the ""Blueberry"" hall were documented as having been checked for proper functioning on the evening shift of 05/04/11. -- b) Resident #43 At 2:25 p.m. on 05/05/11, another LPN (Employee #27) assisted in checking the status of residents with physicians orders for Wanderguard bracelets on the ""Blueberry"" side of the facility. Employee #27 discovered Resident #43's Wanderguard bracelet was not operational. When asked if this resident could get out the door, Employee #27 stated, ""Yes, (Resident #43) can do about anything he wants to."" -- c) Residents #15, #5, #41, #42, #53, #22, #2, #24, #28, #55, #8 and #23. At 2:25 p.m. on 05/05/11, Employee #27 assisted in checking the status of the residents' physician-ordered Wanderguard bracelets on the ""Blueberry"" side of the facility. It was determined that the above residents' Wanderguard bracelets were functioning properly.",2014-09-01
11028,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-06-30,493,F,1,0,3ZBG12,". Based on observation and staff interview, the facility failed to appoint a licensed administrator as required by State law. This deficient practice had the potential to affect all residents who reside at the facility. Facility census: 58. Findings include: a) Observation, on 06/28/11, revealed the facility failed to have a licensed administrator overseein the daily operations of the facility. During an interview on the morning of 06/28/11, the administrative assistant (Employee #55) verified the facility did not have a licensed administrator. She stated she was told the company was interviewing candidates and a new administrator would be hired within the next few weeks. She verified the previous administrator's last date of employment was 06/27/11.",2014-09-01
11029,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,283,D,0,1,KJ9T11,"Based on record review and staff interview, the facility failed to complete a discharge summary for Resident #58 to included a recapitulation of the resident's stay. This was evident for one (1) of two (2) residents whose closed records were reviewed. Facility census: 57. Findings include: a) Resident #58 A review of this resident's medical record revealed she had been discharged to an assisted living facility on 08/25/09. The discharge summary form was not completed by the nursing department nor the activity department staff. Social services, dietary services, and therapy services had completed their sections, but nursing and activities had not. This was discussed with the director of nursing on the late afternoon of 10/15/09, and she was permitted time to provide any additional information. There was no further information regarding this matter provided to surveyors by exit on 10/16/09. .",2014-09-01
11030,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,364,E,0,1,KJ9T11,"Based on observation, individual resident interviews, confidential resident group meeting, and staff interview, it was found that the dietary staff had not prepared manicotti in a manner that was appealing and easy to consume. This was expressed by four (4) of ten (10) residents who attended the resident group meeting. Facility census: 57. Findings include: a) The evening meal was observed on 10/13/09, at which time manicotti was served to residents. In the dining room residents, were noted to leave the item uneaten on their trays. Individual residents observed during meal service on the nursing unit also left this item uneaten. One (1) resident told the surveyor it was too hard to chew and was like ""leather"". This was discussed at the confidential resident group meeting on the afternoon of 10/14/09. Four (4) of ten (10) residents in attendance expressed dislike of the manicotti, saying it was too tough to eat. Staff could cut it with a knife, but the residents could not chew it. This was discussed with the dietary manager and the administrator later in the afternoon of 10/14/09. The dietary manager stated this was not the first time the manicotti was served to residents and, sometimes, it would go over well, and other times it would not. No further evidence was provided by the time of exit regarding this issue. .",2014-09-01
11031,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,363,D,0,1,KJ9T11,"Based on observation, staff interview, and record review, the facility failed to ensure foods were prepared and served in accordance with the planned menu for two (2) residents with orders for finger foods. Resident identifiers: #4 and #8. Facility census: 57. Findings include: a) Residents #4 and #8 Observations of meal service, at lunch on 10/14/09, found dietary staff had not followed the facility's approved menu, by not preparing broccoli for residents with orders for finger foods. The cook (Employee #58) and dietary manager (Employee #47) verified, at that time, the item had not been prepared prior to tray line to have ready for serving. Two (2) residents (#4 and #8) had orders for this type of diet. Employee #58 responded to the inquiry about what items were fixed for finger foods by saying, ""I knew there was something I forgot to get. I did not prepare the broccoli."" .",2014-09-01
11032,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,371,F,0,1,KJ9T11,"Based on observation and staff interview, the facility failed to ensure food was served under sanitary conditions. The temperature of the water in the dishwasher's rinse cycle did not consistently remain above 180 degrees Fahrenheit (F), and the dietary staff did not utilize the correct concentration of sanitizing solution in the three-compartment sink, to ensure dishware and cookware were properly sanitized between uses. These practices have the potential to affect all the residents who consume foods by oral means. Facility census: 57. Findings include: a) During the initial tour and at various times throughout the survey, observation revealed the water temperature of the dishwasher did not consistently reach 180 degrees F as required. The dishwasher itself had a plaque on the outside stating the rinse temperature was to be 180 degrees F. This was brought to the attention of the dietary manager and the maintenance staff after lunch on 10/13/09. Maintenance staff later reported that a part was needed and was now on order. This was also discussed with the administrator on different occasions throughout the survey, who verified that a part was being ordered to repair the machine. b) Right after breakfast on the morning of 10/14/09, the surveyor went to the dietary department to check the dishwasher temperatures. While doing this, observation found the three-compartment sink was filled with water and ready to wash cookware. The surveyor requested the dietary manager to use test strips and check the amount of sanitizer in the third compartment, to see if the concentration was correct. The results of the test strip revealed no sanitizing solution was in the water, and the dietary manager then added the required amount. .",2014-09-01
11033,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,386,D,0,1,KJ9T11,"Based on record review and staff interview, the facility failed to ensure the physician signed and dated all progress notes at each visit. This was evident for one (1) of thirteen (13) sampled residents whose records were reviewed. Resident identifier: #30. Facility census: 57. Findings include: a) Resident #30 The medical record for this resident, when reviewed on 10/14/09, contained a physician's progress note with 10/01/09 noted at the top of the page. At the completion of the note, there was no signature or date of the signature by the physician. This was verified with the director of nursing on the late afternoon of 10/15/09. .",2014-09-01
11034,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,225,D,0,1,KJ9T11,"Based on personnel file review and staff interview, the facility failed to screen one (1) of ten (10) sampled employees for a history of criminal convictions that would indicate the individual was unfit for service in a nursing facility; failed to check the nurse aide registry for one (1) of ten (10) sampled employees for findings of resident abuse / neglect; and failed to complete a statewide background check for one (1) sampled nursing assistant who had worked in another state. Employee identifiers: #9 ,#2, and #27. Facility census: 57. Findings include: a) Employee #9 Employee #9 was hired in 2008. Review of this individual's personnel file found no evidence of a West Virginia statewide criminal background check, nor of having had one requested. On 10/14/09 at approximately 11:00 a.m., the administrator was informed of this finding. No further evidence was produced prior to exit on 10/16/09 b) Employee #2 Employee #2 was hired nearly five (5) months ago. There was evidence in her personnel file that a request for a background check was requested on 05/21/09, but there were no results in her file. On 10/14/09 at approximately 11:00 a.m., the administrator was informed of this finding. No further evidence was produced prior to exit on 10/16/09. c) Employee #27 Employee #27 was a new hire who had a West Virginia statewide criminal background check requested. According to her resume, this employee also worked in a neighboring state in the nursing field. However, there was no evidence of a criminal background check or nurse aide registry check for that state. On 10/14/09 at approximately 11:00 a.m., the administrator was informed of this finding and agreed that a check should also have been done in the neighboring state. .",2014-09-01
11035,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,514,D,0,1,KJ9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete and accurate clinical record on each resident. This was evident for one (1) of thirteen (13) sampled residents which contained conflicting information regarding code status and physician orders. Resident identifier: #2 Facility census: 57. Findings include: a) Resident #2 Review of Resident #2's clinical record revealed conflicting orders regarding her code status and decision to resuscitate in the event of a cardiac and/or respiratory arrest. Her medical record contained a Physician order [REDACTED]. However, the monthly recapitulation of physician orders [REDACTED]. During interview with the director of nursing on 10/14/09 at 12:30 p.m., she said that, if an arrest occurred, the nursing staff would follow the POST form (Do Not Resuscitate). She also said the recapitulation of physician's orders [REDACTED]. These findings were reported to the administrator on 10/15/09 at 9:40 a.m., and she spoke understanding of the need to have clarification of the current status.",2014-09-01
11036,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,166,E,0,1,KJ9T11,"Based on resident interview, record review, confidential resident group interview, review of the resident council meeting minutes, and staff interview, the facility failed to make prompt efforts to resolve residents' grievances. This was evident for nine (9) of ten (10) residents in a confidential group meeting and two (2) of thirteen (13) sampled residents. Resident identifiers: #43 and #49 (identifiers of residents attending the group meeting are confidential). Facility census: 57. Findings include: a) Residents #49 and #43 Two (2) female residents reported a male resident on their hall allegedly made unwelcome sexual gestures toward them on many occasions which made them feel very uncomfortable; this problem was reported to the facility but had not been resolved. 1. Resident #49 During an interview with Resident #49 on 10/15/09 at 3:30 p.m., she stated the man next door grabs his ""privates"" through his clothing and shakes himself at her. When questioned, she said he did not expose flesh nor touch her in any way or talk to her. She said once a nurse saw him do this and told him to stop because it wasn't nice. She was unable to give a time frame as to when this last occurred, but she stated he had done this to her many times since she returned from the hospital in September 2009, and he had done this prior to that hospitalization as well. When asked if she told anyone about this, she replied, ""They all know about it"", and added she spoke to the administrator about it last week and complained to a nurse aide yesterday, who allegedly relayed it to a nurse in charge. When asked if she considered moving, she replied in the negative, citing another move with her health conditions was not good. 2. Resident #43 An interview with Resident #43, on 10/15/09 at 3:45 p.m., revealed she, too, was uncomfortable with this same male resident coming out into the hallway and making sexual gestures in front of her and her roommate. She said she and her roommate finally got fed up with it, and they complained to the administrator this week about the situation. 3. During an interview with the director of nursing (DON) on 10/15/09 at approximately 4:00 p.m., she said, most likely, Resident #49 is sitting at her doorway when the male resident comes out of his room and walks down the hallway past her. When asked about room changes, she explained Resident #43 had received a room change to her current room at her request and she did not want to move again. 4. During an interview with the administrator on 10/16/09 at approximately 9:00 a.m., she said Resident #49, Resident #43, and her (#43's) roommate had recently approached her with complaints about the male resident making sexual gestures that they disliked. She explained that interventions were in place, and this problem had been addressed in the male resident's care plan. She said the facility's newly hired social worker ended employment after only two (2) weeks, and the facility had been actively advertising for that position. In the interim, they have contracted a licensed social worker consultant whose first day of employment was 10/12/09 and who will work at the facility two (2) days per week until that position is filled. 5. Review of the male resident's care plan revealed a problem area, dated 09/10/09, related to him exposing himself to female residents and a goal of not exhibiting that behavior. -- b) During a confidential group interview with residents on 10/14/09 at 2:30 p.m., nine (9) of ten (10) residents in attendance reported not having enough daily activities and also reported not getting to go outside the facility on outings due to not having a van. One (1) resident reported there had not been any outings since her arrival in February. Residents said they have to get an ambulance for any appointments outside the facility if they do not have family or friends who can transport them. Review of the previous three (3) months' resident council meeting minutes revealed the request for a facility van was brought up during each of these meetings as follows: on 07/27/09, residents requested a Wal-Mart trip and a stop at a local fast food restaurant; on 08/31/09, residents had questions regarding when the van would be available; on 09/28/09, residents again brought up questions about the van. During an interview with the administrator on 10/15/09 at 12:15 p.m., she stated the old van was unsafe, so a new van was purchased in mid-August. However, they still have no title for this van, which was purchased from another state. During the exit conference with department heads on 10/16/09 at 12:00 p.m., the activity director reported their last activity outing occurred in May 2009 for the Geri Olympics. -- c) Absence of a cordless phone for resident use Review of the 09/28/09 resident council meeting minutes revealed a request for a cordless phone was discussed, as were ongoing plans to obtain one (1) for resident use. During the confidential group meeting on 10/14/09 at 2:30 p.m., residents reported a cordless phone had not yet been obtained. During an interview on 10/15/09 at 3:30 p.m., Resident #49 said she would like to have a cordless phone so she can make and receive phone calls in her room; currently, a resident must go to the nurse's station for phone calls or may take phone calls in the lounge, but this was not feasible for residents with little or no ability to travel independently to other locations. During an interview with the administrator on 10/15/09 at 12:15 p.m., she said they still had no cordless phone and will have to figure out how to tie it in with their phone system. She agreed bedfast residents were not able to make or receive phone calls unless they had their own phone or had a portable phone brought to them. .",2014-09-01
11037,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,323,E,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, staff interview, and observation, the facility failed to assure the residents' environment was as free of accident hazards as possible. Water temperatures were too hot in residents' hand sinks, a resident was not ambulated as ordered to prevent falls, and a treatment cart was left unlocked and unattended in the hallway. These practices had the potential to affect one (1) sampled resident and all residents who could ambulate independently. Resident identifier: #51. Facility census: 55. Findings include: a) Water temperatures On 05/22/09, temperatures of hot water were taken with the facility's environment services supervisor (ESS). The water temperatures were taken of the hand sinks on ""B,"" ""C,"" and ""D"" Halls, with the following findings which exceeded the maximum safe temperature (110 degrees F): - B-2 was 118 degrees F at 10:08 a.m. - C-3 was 116 degrees F at 10:10 a.m. - D-1 was 116.8 degrees F at 10:10 a.m. Interview with the ESS, at 9:45 a.m. on 05/22/09, revealed he mistakenly believed 110 degrees F was the minimum allowable temperature in resident areas, instead of the maximum allowable temperature. Record review revealed water temperatures were being taken, but the exact temperatures were not being recorded. A check mark was being placed beside 110 degrees F. According to the ESS, this check meant the hot water was 110 degrees F or above. b) Resident #51 Medical record review revealed an order for [REDACTED]. This information was also found on the closet sheet. At noon on 05/22/09, this resident was observed being ambulated to and from the dining room without being followed with a wheelchair, creating an accident hazard for this resident. c) Treatment cart On 05/21/09 at 11:45 a.m., random observations of the resident environment found s treatment cart parked in the ""C"" hallway with no staff members present in the hallway. Inspection of the treatment cart found it had been left unlocked and stocked with treatment supplies which included numerous creams and ointments. The treatment cart remained unsupervised and unlocked in the resident hallway for five (5) minutes. A nursing staff member was observed to exit a resident room, which previously had the door closed. She stated she had forgotten to lock her cart. .",2014-09-01
11038,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,332,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure medication were administered with an error rate below 5 percent (5%). Facility nursing staff members made three (3) medication errors with an opportunity for fifty-three (53) errors for an overall error rate of 5.6 %. This deficient practice affected three (3) of seven (7) residents receiving medications. Resident identifiers: #55, #37, and #35. Facility census: 55. Findings include: a) Resident #55 Observations of the medication administration pass, on 05/20/09 at 9:10 a.m., found the nurse pouring liquid Potassium into a plastic medication cup. Review of the medication administration record (MAR) noted the physician ordered Resident #55 to receive 7.5 cc of liquid Potassium. The nurse was asked to measure the amount of liquid Potassium present in the cup by using a syringe. The nurse determined the cup only contained 6.25 cc of liquid Potassium. b) Resident #37 Observation of the medication administration pass, on 05/21/09 at 9:15 a.m., found the nurse preparing medications for Resident #37. Review of the MAR noted the resident was to receive 150 mg of [MEDICATION NAME]. Inspection of the bottle of [MEDICATION NAME] utilized by the nurse revealed each tablet contained 75 mg. of [MEDICATION NAME]. The nurse placed one (1) tablet of [MEDICATION NAME] into the resident's medication cup and administered it to the resident along with her other medications. The nurse was asked to again review the MAR and bottle of medication following the administration. She agreed the she should have administered two (2) tablets of [MEDICATION NAME] to the resident. c) Resident #35 Review of the medical record found Resident #35 was prescribed [MEDICATION NAME] 120 mg three-times-a-day (TID) before each meal for treatment of [REDACTED]. Observations of the resident, on the morning of 05/21/09, found no nurse administered [MEDICATION NAME] prior to the noon meal. Review of the MAR, on 05/21/09 at 1:30 p.m., found a nurse had not initialed the [MEDICATION NAME] had been administered to the resident. An interview with the assigned nurse, on 05/21/09 at 1:30 p.m., confirmed the nurse did not administer the [MEDICATION NAME] prior to the noon meal. .",2014-09-01
11039,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,428,F,0,1,ETK911,"Based on medical record review and staff interview, the facility failed to assure a licensed pharmacist conducted a review of each resident's drug regimen at least once a month. This deficient practice affected all residents currently residing in the facility. Facility census: 55. Findings include: a) Review of thirteen (13) medical records found no evidence a licensed pharmacist conducted a drug regimen review for the month of April 2009. An interview with the director of nursing (DON), on the morning of 05/20/09, confirmed a drug regimen review was not conducted by a licensed pharmacist in April 2009. .",2014-09-01
11040,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,441,D,0,1,ETK911,"Based on random observation and review of facility policy, the facility failed to assure nurses administered eye drops in a manner to prevent the potential spread of infection for two (2) of two (2) eye drop administrations observed. Resident identifiers: #55 and #50. Facility census: 55. Findings include: a) Resident #55 During observations of the medication administration pass on 05/21/09 at 9:10 a.m., the nurse (Employee #52) administered eye drops to Resident #55. The nurse did not wash or sanitize her hands. She removed gloves from a box in the room, wadded them up in her hands, carried the resident's oral medications and bottle of eye drops into the resident's room, then removed another pair of gloves from the box in the room and placed them into her uniform pocket. The nurse administered the resident's oral medications. She then removed a pair of gloves from her uniform pocket, donned the contaminated gloves, and administered one (1) drop of medication into each of the resident's eyes. The director of nursing (DON) provided the facility's policy on the instillation of eye drops at 10:30 a.m. on 05/20/09. Review of the policy section entitled ""Infection Control Protocol and Safety"" (revised August 2002) found the following instructions: ""1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure; ... ."" b) Resident #50 On 05/21/09 at 9:15 a.m., the nurse (Employee #30) administered eye drops to each of Resident #50's eyes. During this administration, the nurse allowed the tip of the eye drop bottle to come into contact with the lashes of the resident's left eye. .",2014-09-01
11041,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,502,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of one (1) of thirteen (13) sampled residents. Resident identifier: #1. Facility census: 55. Findings include: a) Resident #1 Review of the medical record found a physician's orders [REDACTED]. The medical record contained no evidence the facility had obtained the ordered laboratory test for this resident. An interview with the director of nursing (DON), on 05/21/09 at 12:00 p.m., confirmed the facility did not obtain the ordered laboratory test. .",2014-09-01
11042,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,225,E,0,1,ETK911,"Based on review of the facility's complaint records and staff interview, the facility failed to thoroughly investigate allegations of neglect upon receipt, and failed to report licensed healthcare professionals involved in instances of neglect to the appropriate licensing boards, and failed to assure staff immediately reported all allegations of neglect to the facility's administrator. These practices were evident for six (6) of ten (10) allegations reviewed. Resident identifiers: #5, #6, #35, #57, and #58. Facility census: 55. Findings include: a) Resident #6 On 01/06/09, Resident #6 reported to the facility she sometimes turned on her bathroom light and was not assisted for several minutes. The facility interviewed assigned nursing assistants and took statements. In one (1) of these statements, a nursing assistant identified by name another nursing assistant who had also helped the resident on the 7-3 shift on 01/06/09. The facility did not interview this other nursing assistant and/or obtained a statement from him/her. b) Resident #35 On 01/30/09, Resident #35's family expressed concern that the resident might not be getting showers on her scheduled shower days. The facility's investigation indicated statements were collected from nursing staff; however, upon request, the facility could not produce these statements. On 03/10/09, this resident's family again expressed concern that the resident was not receiving her scheduled showers. There was no investigation of this allegation; the facility only obtained statements from staff regarding what was supposed to occur regarding residents and their shower days. In addition, the family also expressed concern that the resident's personal items were being used for other residents. This concern was not addressed at all. c) Resident #5 On 02/20/09, Resident #5 reported she had not been receiving her medications for her mouth since admission on 02/05/09. The facility investigated the situation and disciplined several nurses for failing to order the medication and/or failing to assure the resident received the medication as ordered; however, the facility did not report the nurses involved in this neglect to the appropriate licensing board. d) Resident #57 On 03/04/09, the nursing assistant for this resident (who no longer resides in the facility) provided a statement indicating she had informed C.L., a licensed practical nurse (LPN), the resident had a scratch on her leg which needed to be checked by the LPN. The facility investigated the situation and substantiated the LPN did not assess the resident's leg. The facility did not report this neglect to the appropriate licensing board. e) Resident #58 On 03/02/09, a nursing assistant (Employee #17) made a complaint regarding C.L. (LPN) regarding the nurse's failure to check on Resident #58. The nursing assistant stated, ""Around a week and a half ago ... she (the resident) was really pale in color and had diarrhea X 6."" The nursing assistant stated the LPN did not do anything for the resident after she was given this information. The nursing assistant did not immediately report this allegation of neglect to facility administration, and there was no evidence this failure to report was addressed. f) During an interview on the afternoon of 05/20/09, the social worker was unable to provide any additional information regarding the above-referenced concerns. .",2014-09-01
11043,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,364,F,0,1,ETK911,"Based on observation and staff interview, the facility failed to assure potatoes were prepared by a method which conserved nutritional value. They were soaked in water, creating a loss of nutrients. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Finding include: a) On 05/18/09 at 2:00 p.m., observation revealed a large pan of potatoes in a large amount of water in the cooler. Upon inquiry, at that time, the cook stated the potatoes were for the following day. Further inquiry revealed the water would be drained off and discarded. This practice creates a loss of potassium in the potatoes. This process is called ""leaching"" and is used when potassium needs to be removed from potatoes for potassium restricted diets.",2014-09-01
11044,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,315,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to provide services and treatment to restore as much normal bladder function as possible for one (1) of twelve (12) sampled residents. The facility did not assess one (1) of thirteen (13) sampled residents or put individualized measures in place to help restore continence when a resident had a decline in bladder continence. Resident identifier: #12. Facility census: 55. Findings include: a) Resident #12 Medical record review, on 05/20/09, revealed this resident had an indwelling Foley urinary catheter when she was admitted on [DATE]. The facility implemented a bladder training schedule for discontinuation of the catheter on 08/20/08, 08/21/08 and 08/23/08, and the catheter was discontinued at 12:00 a.m. on 08/23/08. A bladder assessment was completed on 10/13/08. This assessment indicated the resident was continent of bladder. Review of the resident's minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/08/09, revealed the resident's bladder continence was coded ""2"", indicating occasional bladder incontinence. This coding represents incontinence two (2) or more times a week, but not daily. Review of the resident's MDS, with an ARD of 05/03/09, revealed the resident was coded ""3"", indicating frequent bladder incontinence. This coding represents incontinence daily. Review of the resident's care plan, dated 05/05/09, revealed the following problem: ""Having incontinence of bowel and bladder which has worsened."" The interventions for this problem did not include anything regarding assessment for causal factors. The interventions described the resident had declined a toileting schedule. There was no evidence of any other plans to assist the resident in becoming continent and/or less incontinent. The facility's urinary continence and incontinence assessment and management policy, provided by the director of nursing (DON), instructed facility staff to complete ongoing assessments of a resident's diagnoses, physical and cognitive functioning, and environment factors, to name a few, to determine possible causal factors for incontinence. The policy also directed staff to identify risk factors, complete a review of medications, assess voiding patterns, and to identify other risk factors for becoming incontinent or for worsening of current incontinence. There was no evidence that this had been done for this resident. On 05/22/09 at 3:30 p.m., a discussion was held with the DON regarding this resident's incontinence and what assessment the facility had initiated to determine causal factors and/or appropriate plans to assist the resident in becoming continent, or less incontinent. At that time, the DON had no additional information to provide regarding what the facility had implemented to assess whether this resident's worsening incontinence had the potential to be reversed. .",2014-09-01
11045,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,246,D,0,1,ETK911,"Based on observation and staff interview, the facility failed to made reasonable accommodations with staff's routine and/or practices to ensure residents received timely assistance with toileting to maintain independent functioning and dignity. This affected two (2) residents of random observation. Resident identifiers: #39 and #51. Facility census: 55. Findings include: a) Residents #51 and #39 After the noon meal on 05/22/09 at 1:45 p.m., observation found Resident #51 waiting for a staff member to take her to the bathroom. Upon inquiry, the resident stated she had already asked staff to take her, but they have not ""gotten to me yet"". The resident then stated, ""If I don't go to the bathroom soon, I'm gonna go. I know what everyone feels like now when they've gotta go and no one to take them."" Further discussion revealed staff told the resident she would have to wait until the trays were picked up to be taken to the bathroom. A few minutes later, the resident was taken to her room and into the bathroom. While Resident #51 was in the bathroom, her roommate (Resident #39) was brought to the entrance of their room to be taken to the bathroom. When Resident #39 was informed Resident #51 was in the bathroom, Resident #39 stated she had to go ""now"" and ""I am about to wet myself."" A nursing assistant and a nurse were just outside the door when this occurred. When asked what should be done in this situation, the nurse stated, ""That's a good question. This has not come up before."" Neither nursing staff member considered, or took, Resident #39 to a different bathroom. .",2014-09-01
11046,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2011-05-25,353,E,1,0,KMQI11,". Based on record review, staff interview, and resident interview, the facility failed to provide sufficient staffing to ensure ten (10) of sixteen (16) sampled residents received showers twice weekly in accordance with the facility's shower schedule and the residents' care plans. This practice had the potential to affect all residents residing on the 300 and 400 units. Resident identifiers: #4, #18, #31, #32, #58, #65, #67, #82, #84, and #93. Facility census: 98. Findings include: a) Residents #4, #18, #31, #32, #58, #65, #67, #82, #84, and #93 In an interview with an anonymous complainant on the morning of 05/23/11, the complainant reported a concern that the nursing staffing levels on the 300 and 400 units were not sufficient to ensure that residents on these units received showers as often as they were supposed to. The complainant stated that several of the residents on the 300 unit were confused and incontinent, requiring lots of hands-on care, and that care could not be provided with just the one (1) aide assigned to that unit. When reminded that there was also a nurse present, the complainant stated the nurse had too much to do to assist the aide with personal care. A review of the shower schedule found all sixteen (16) sampled residents were supposed to receive showers twice weekly. When the activities of daily living (ADL) tracking forms for each resident were reviewed, ten (10) of the sampled residents did not receive twice weekly showers with no explanation as to why these showers were not provided. There was evidence that scheduled showers had not been provided to these residents in January, February, March, April, and/or May 2011. - 1. Resident #4 Resident #4 was scheduled for nine (9) showers in May and only received three (3). - 2. Resident #18 Resident #18 was scheduled for eight (8) showers in February, nine (9) in March, and eight (8) in May. The resident received only three (3) showers in February, two (2) showers in March, and three (3) showers in May (two (2) of which were on the same day). Review of the resident's annual comprehensive assessment, with an assessment reference date (ARD) 04/04/11, found the resident did not resist care and required ""oversight help only"" for hygiene and bathing. She was ambulatory with supervision only and had no balance problems. Her care plan, dated 05/11/11, stated the resident had ""episodes of resisting care ex. bathing."", but there were no interventions planned and no evidence that these missed showers were refused. The resident filed a grievance on 04/15/11, stating there was ""only one aide on floor and cannot give bath (sic) have to wait until next shift or until someone comes on."" - 3. Resident #31 Resident #31 was scheduled for eight (8) showers February, nine (9) showers in March, and nine (9) showers in May. The resident received only (2) showers in February, one (1) shower in March, and five (5) showers in May. Her care plan stated she required total care, was incontinent of bowel and bladder and ""plays with feces"", but there was no evidence that she did not cooperate with bathing or that she refused assistance with personal hygiene maintenance. Her annual comprehensive assessment indicated there were no behaviors. On 05/16/11, her family filed a grievance stating that, when visiting, they found her hair and nails ""full of feces"". - 4. Resident #32 Resident #32 received none (0) of the eight (8) schedule showers in February and none (0) of the eight (8) scheduled showers in March. The resident's care plan stated the resident was incontinent of bowel and bladder, for which an intervention stated to ""keep clean and dry"". There was no evidence in the record that Resident #32 refused baths or that there were any problems with giving this resident showers / baths. - 5. Resident #58 Resident #58 received only two (2) of the eight (8) scheduled showers in May. Although the resident was receiving hospice services, there was no documentation in the care plan stating that showers should not be given. - 6. Resident #65 Resident #65 was scheduled for eight (8) showers in January, six (6) showers in February, and seven (7) showers in March. The resident received none (0) of these twenty-one (21) scheduled showers. The care plan indicates stated this resident was totally dependent on staff for ADL performance and required the use of a Hoyer lift for transfers, but there was no mention in the care plan that showers were not to be given to this resident. - 7. Resident #67 Resident #67 was scheduled for eight (8) showers in May and only received three (3) of them. The care plan revealed no reason for providing this resident with showers. - 8. Resident #82 Resident #82 received only six (6) of nine (9) showers scheduled in March. This resident's admission assessment indicated he could bathe himself with supervision only. Review of his care plan and nursing notes found no documented reason(s) for the missed showers. - 9. Resident #84 Resident #84 received only four (4) of nine (9) showers scheduled in May. This resident's care plan indicated she needed ""set-up, assist, give-shower, shave, oral, hair, nail care per schedule and PRN"". Her admission assessment with an ARD of 04/07/11, found in Section F0400 that when asked, ""How important is it for you to choose between tub bath, bed bath, or sponge bath?"" her response was recorded as ""Very Important"" and showers were planned for her care. She was totally dependent on staff for all ADLs. - 10. Resident #93 Resident #93 received only six (6) of nine (9) showers scheduled in March. There was no evidence in the record of any refusal of care or physical reason for her missed showers. -- b) Residents #18, #58, #82, #31, #65, and #84 were interviewed individually and asked if they received two showers weekly and, if not, why not. None (0) of the residents said they always received two (2) showers each week. Resident #18, when interviewed on the afternoon of 05/23/11, stated the aide frequently states she doesn't have time to take her to the shower. She stated that many of the residents ""act up a lot"" and the aide has to be available to take care of them. She stated that she doesn't think one (1) person (nurse) can take care of all the other residents on the hall while the aide gives her a shower. (There were eighteen (18) residents on this hall.) -- c) During an interview with a nursing assistant (Employee #63) at 3:15 p.m. on 05/25/11, he stated that when he takes breaks and leaves the unit, the nurse covers for him. He also stated that he tries to give residents their showers after supper when residents are settled, and added that he often does showers that are scheduled for day shift as it is calmer on the evening shift. He was assigned to the 400 hall, which was also staffed with one (1) nurse and (1) aide per shift, but only had ten (10) residents. During individual interviews with Employees #68 and #52 (both nursing assistants) at 3:50 p.m. on 05/25/11, they each stated they were responsible for showers in addition to the routine care of the residents on the 300 unit. Neither said that they understood they were to obtain assistance from an aide on another floor when giving showers. They explained that they inform the nurse when they are going to be in the shower room, so that she can watch the floor, and they obtain her assistance if necessary when transferring residents. They also stated they were responsible for documenting the status of each resident's skin on the skin check sheet and the type of bath given on the ADL record. They stated the information on the ADL sheets was correct, even when it was not the type of bath ordered. Four (4) direct care employees, who wished to remain anonymous, were asked if the residents received two (2) showers weekly and, if not, why not. They all stated they did not get all the showers done and added that they truthfully documented when they couldn't get to them. They all agreed they don't ask for help, because they know the others aides are just as busy. One (1) of the employees stated that showers were the only tasks not completed on a regular basis, and the others agreed. They stated that, because of the supervision required by the residents, they just couldn't go into the shower room for fifteen (15) to twenty (20) minutes, because one person (the nurse) wasn't enough to safely watch the remaining residents. When asked if they had discussed this with administration, two (2) said they had complained to the union, and one (1) said she had told the director of nursing (DON) that they needed help. All stated that the nurses on the floors knew that all residents did not receive two (2) showers per week. -- d) During an interview with the DON (Employee #1), who was also on the facility's quality assurance (QA) committee, and the administrator at 4:20 p.m. on 05/25/11, the DON was asked what care areas were presently being addressed in QA. She stated that the only ""care areas"" addressed at present were those ""high risk"" areas, like falls. She had no comment when presented with the findings that residents on all units were not receiving showers as scheduled and care planned, especially on the 300 unit. They stated there was no written facility policy addressing the frequency of showers, but they acknowledged that residents are scheduled for two (2) showers weekly and that this was what the families are told. When informed that the reason given by several staff members for not completing the showers as scheduled was that they did not have enough help, the administrator agreed he would look into it and stated he had not been aware of a problem. The DON again stated that there was no ""scheduled"" staff to assist with baths. She had no answer when asked how she expected a resident requiring a 2-person assist to be bathed when the unit was only staffed with two (2) staff members, as this was the staffing level routinely found on the 300 and 400 units.",2014-09-01
11047,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2011-05-25,282,E,1,0,KMQI11,". Based on record review, staff interview, and resident interview, the facility failed to provide showers as scheduled and/or at a frequency of twice weekly to ten (10) of sixteen (16) sampled residents in accordance with the facility's shower schedule and the residents' care plans. Resident identifiers: #4, #18, #31, #32, #58, #65, #67, #82, #84, and #93. Facility census: 98. Findings include: a) Residents #4, #18, #31, #32, #58, #65, #67, #82, #84, and #93 In an interview with an anonymous complainant on the morning of 05/23/11, the complainant reported a concern that the nursing staffing levels on the 300 and 400 units were not sufficient to ensure that residents on these units received showers as often as they were supposed to. The complainant stated that several of the residents on the 300 unit were confused and incontinent, requiring lots of hands-on care, and that care could not be provided with just the one (1) aide assigned to that unit. When reminded that there was also a nurse present, the complainant stated the nurse had too much to do to assist the aide with personal care. A review of the shower schedule found all sixteen (16) sampled residents were supposed to receive showers twice weekly. When the activities of daily living (ADL) tracking forms for each resident were reviewed, ten (10) of the sampled residents did not receive twice weekly showers with no explanation as to why these showers were not provided. There was evidence that scheduled showers had not been provided to these residents in January, February, March, April, and/or May 2011. - 1. Resident #4 Resident #4 was scheduled for nine (9) showers in May and only received three (3). - 2. Resident #18 Resident #18 was scheduled for eight (8) showers in February, nine (9) in March, and eight (8) in May. The resident received only three (3) showers in February, two (2) showers in March, and three (3) showers in May (two (2) of which were on the same day). Review of the resident's annual comprehensive assessment, with an assessment reference date (ARD) 04/04/11, found the resident did not resist care and required ""oversight help only"" for hygiene and bathing. She was ambulatory with supervision only and had no balance problems. Her care plan, dated 05/11/11, stated the resident had ""episodes of resisting care ex. bathing."", but there were no interventions planned and no evidence that these missed showers were refused. The resident filed a grievance on 04/15/11, stating there was ""only one aide on floor and cannot give bath (sic) have to wait until next shift or until someone comes on."" - 3. Resident #31 Resident #31 was scheduled for eight (8) showers February, nine (9) showers in March, and nine (9) showers in May. The resident received only (2) showers in February, one (1) shower in March, and five (5) showers in May. Her care plan stated she required total care, was incontinent of bowel and bladder and ""plays with feces"", but there was no evidence that she did not cooperate with bathing or that she refused assistance with personal hygiene maintenance. Her annual comprehensive assessment indicated there were no behaviors. On 05/16/11, her family filed a grievance stating that, when visiting, they found her hair and nails ""full of feces"". - 4. Resident #32 Resident #32 received none (0) of the eight (8) schedule showers in February and none (0) of the eight (8) scheduled showers in March. The resident's care plan stated the resident was incontinent of bowel and bladder, for which an intervention stated to ""keep clean and dry"". There was no evidence in the record that Resident #32 refused baths or that there were any problems with giving this resident showers / baths. - 5. Resident #58 Resident #58 received only two (2) of the eight (8) scheduled showers in May. Although the resident was receiving hospice services, there was no documentation in the care plan stating that showers should not be given. - 6. Resident #65 Resident #65 was scheduled for eight (8) showers in January, six (6) showers in February, and seven (7) showers in March. The resident received none (0) of these twenty-one (21) scheduled showers. The care plan indicates stated this resident was totally dependent on staff for ADL performance and required the use of a Hoyer lift for transfers, but there was no mention in the care plan that showers were not to be given to this resident. - 7. Resident #67 Resident #67 was scheduled for eight (8) showers in May and only received three (3) of them. The care plan revealed no reason for providing this resident with showers. - 8. Resident #82 Resident #82 received only six (6) of nine (9) showers scheduled in March. This resident's admission assessment indicated he could bathe himself with supervision only. Review of his care plan and nursing notes found no documented reason(s) for the missed showers. - 9. Resident #84 Resident #84 received only four (4) of nine (9) showers scheduled in May. This resident's care plan indicated she needed ""set-up, assist, give-shower, shave, oral, hair, nail care per schedule and PRN"". Her admission assessment with an ARD of 04/07/11, found in Section F0400 that when asked, ""How important is it for you to choose between tub bath, bed bath, or sponge bath?"" her response was recorded as ""Very Important"" and showers were planned for her care. She was totally dependent on staff for all ADLs. - 10. Resident #93 Resident #93 received only six (6) of nine (9) showers scheduled in March. There was no evidence in the record of any refusal of care or physical reason for her missed showers. -- b) Residents #18, #58, #82, #31, #65, and #84 were interviewed individually and asked if they received two showers weekly and, if not, why not. None (0) of the residents said they always received two (2) showers each week. Resident #18, when interviewed on the afternoon of 05/23/11, stated the aide frequently states she doesn't have time to take her to the shower. She stated that many of the residents ""act up a lot"" and the aide has to be available to take care of them. She stated that she doesn't think one (1) person (nurse) can take care of all the other residents on the hall while the aide gives her a shower. (There were eighteen (18) residents on this hall.) -- c) During an interview with a nursing assistant (Employee #63) at 3:15 p.m. on 05/25/11, he stated that when he takes breaks and leaves the unit, the nurse covers for him. He also stated that he tries to give residents their showers after supper when residents are settled, and added that he often does showers that are scheduled for day shift as it is calmer on the evening shift. He was assigned to the 400 hall, which was also staffed with one (1) nurse and (1) aide per shift, but only had ten (10) residents. During individual interviews with Employees #68 and #52 (both nursing assistants) at 3:50 p.m. on 05/25/11, they each stated they were responsible for showers in addition to the routine care of the residents on the 300 unit. Neither said that they understood they were to obtain assistance from an aide on another floor when giving showers. They explained that they inform the nurse when they are going to be in the shower room, so that she can watch the floor, and they obtain her assistance if necessary when transferring residents. They also stated they were responsible for documenting the status of each resident's skin on the skin check sheet and the type of bath given on the ADL record. They stated the information on the ADL sheets was correct, even when it was not the type of bath ordered. Four (4) direct care employees, who wished to remain anonymous, were asked if the residents received two (2) showers weekly and, if not, why not. They all stated they did not get all the showers done and added that they truthfully documented when they couldn't get to them. They all agreed they don't ask for help, because they know the others aides are just as busy. One (1) of the employees stated that showers were the only tasks not completed on a regular basis, and the others agreed. They stated that, because of the supervision required by the residents, they just couldn't go into the shower room for fifteen (15) to twenty (20) minutes, because one person (the nurse) wasn't enough to safely watch the remaining residents. When asked if they had discussed this with administration, two (2) said they had complained to the union, and one (1) said she had told the director of nursing (DON) that they needed help. All stated that the nurses on the floors knew that all residents did not receive two (2) showers per week. -- d) During an interview with the DON (Employee #1), who was also on the facility's quality assurance (QA) committee, and the administrator at 4:20 p.m. on 05/25/11, the DON was asked what care areas were presently being addressed in QA. She stated that the only ""care areas"" addressed at present were those ""high risk"" areas, like falls. She had no comment when presented with the findings that residents on all units were not receiving showers as scheduled and care planned, especially on the 300 unit. They stated there was no written facility policy addressing the frequency of showers, but they acknowledged that residents are scheduled for two (2) showers weekly and that this was what the families are told. When informed that the reason given by several staff members for not completing the showers as scheduled was that they did not have enough help, the administrator agreed he would look into it and stated he had not been aware of a problem. The DON again stated that there was no ""scheduled"" staff to assist with baths. She had no answer when asked how she expected a resident requiring a 2-person assist to be bathed when the unit was only staffed with two (2) staff members, as this was the staffing level routinely found on the 300 and 400 units. .",2014-09-01
11048,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,152,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to a ""[MEDICAL CONDITION]"" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. c) Resident #131 Closed medical record review, on 06/25/09, revealed Resident #131 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 02/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to the [DIAGNOSES REDACTED]. The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The DON,when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. d) Resident #19 Medical record review for Resident #19 revealed the physician's determination of capacity stated Resident #19 demonstrated incapacity to understand and make informed medical decisions and indicated, with a check mark, the [DIAGNOSES REDACTED]. There was NO further information regarding cause or nature, as required by State law. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he confirmed the physician had not filled in all the required information on the determination of capacity form. e) Per W.Va. Code 16-30-7. Determination of incapacity: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-09-01
11049,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,253,E,0,1,OJEL11,"Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a clean, comfortable, homelike environment for two (2) of three (3) halls observed. Walls were observed to be dirty, and walls and doors were in need of repair and paint. Bathroom toilets were leaking at the tank and around the base, and two (2) toilets were noted to have towels placed at their bases to catch dripping water. Bathroom sinks were observed to have dripping faucets. These deficient practices affected more than an isolated number of residents. Facility census: 128. Findings include: a) Observations of the front entrance and 100 hall 1. On 06/24/09 at 9:10 a.m., observations of the front entrance to the building and the 100 hall revealed the following: - The front foyer was observed to have a dirty floor, especially around a metal plate covering a opening to drain system. - The public women's restroom was observed to have cracked and stained caulk at the bottom of the toilet, which was malodorous. - The 100 hall corridor was observed to be stained, with built-up dirt in cracks and along the cove base. 2. Observations of individual rooms on 100 hall revealed the following: - Room 102 - bathroom door was scratched up and did not close properly. - Room 104 - sink in the bathroom was dripping, floor stained, toilet running, spackling on the wall not sanded or painted, and noticeably dirty. - Room 105 - bathroom sink dripping, base of toilet had cracked and stained caulking, floor stained, bathroom was malodorous. - Room 106 - wall behind bed where new light had been installed needed to be patched and painted. - Room 107 - bathroom sink dripping, towel placed behind toilet bowl catching leaking water. - Room 109 - resident room dirty with visible dirt / debris along the cove base, bathroom sink dripping, base of toilet had stained and cracked caulking, bathroom was malodorous. - Room 110 - toilet running continuously, which did not stop with movement of the toilet handle. - Room 116 - bathroom sink dripping, bathroom wall chipped and cracked - Room 117 - bathroom sink dripping and bathroom door chipped and scratched up. - Room 119 - toilet running continuously, which did not stop with movement of the toilet handle. - Room 120 - resident room dirty with dirt and debris along the cove base - Room 121 - bathroom sink dripping - Room 123 - bathroom cover base missing. - Room 125 - bathroom sink dripping. 3. On the afternoon of 06/25/09, the director of nursing (DON - Employee #82), when interviewed, acknowledged they were aware of the environmental issues with the building and were in the process of taking corrective action. b) Observations of 300 hall 1. During the initial tour of the facility on 06/22/09, and during subsequent tours of the facility, the following observations were made on the 300 hall: - On 06/22/09 at 3:00 p.m., observation of the central shower room on the 300 hall found the commode was full of feces, there was a fecal smear on the floor, and a wet towel was also laying in the floor. At 4:30 p.m., repeat observations of the shower room found it unchanged. A facility nurse (Employee #86), when asked to observe the room, confirmed the findings. - On 06/24/09 at 11:00 a.m., Room #311 had chips and tears in the dry wall. - Room 312 - food particles in the top of the air conditioning unit and the baseboards had crusty build-up in the corners of the room. - Room 314 - had a dirty air conditioning unit, with dust and debris in the top of it. - Room 315 - had dirty floors in the bathroom, the floor tile was brown around the walls of the bathroom, and the commode had several layers of caulking at its base. - Room 316 - had walls at the bathroom entrance that were deeply scuffed and chipped. - Room 317 - had walls at the bathroom entrance that were deeply scuffed and chipped - Room 321 - was noted to have deep scuffs in the dry wall; the wall at the bathroom entrance was scuffed and in need of painting. Around the base of the commode were several layers of caulking, and the corners of the bathroom tile were brown and discolored. - Room 318 - had dirty floors, and the commode had several layers of caulking at its base. - Room 319 - had scuffs and tears in the dry wall, and the bathroom commode had several layers of caulking at its base. - Room 320 - had damage to the walls, scuffing and tears in the drywall, the baseboards at the corners of the room were dirty with crusted materials, the air conditioning unit had debris in the top of it. - Rooms 301 and 303 - had dirty air conditioning units with dust and debris in the top. 2. Several of these findings were bought to the attention of the DON at the time of these observations. The DON confirmed the scuffed walls, dirty air conditioning units, and layers of caulking at the base of the commodes. .",2014-09-01
11050,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,272,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Long Term Care News Safety Alert January 2005 issued by the State survey and certification agency, review of the [MEDICATION NAME] low air loss mattress manufacturer's operating manual, and staff interview, the facility failed, for ten (10) of twenty-eight (28) sampled residents, to complete bed safety assessments for residents using a speciality mattress in conjunction with side rails, in order to identify and mitigate bed safety hazards. Resident identifiers: #4, #33, #43, #51, #66, #84, #103, #104, #114, and #129. Facility census: 128. Findings include: a) Observation Initial tour of the facility, on 06/22/09 at 2:30 p.m., revealed the facility had in use several speciality air beds. Further investigation revealed the [MEDICATION NAME] low air loss mattress systems in use were owned (not rented) by the facility. --- b) Safety Alert In January 2005, the State survey and certification agency issued to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes a Safety Alert regarding bed safety and entrapment hazards, which contained the following: ""... It is highly recommended that all licensed nursing homes and/or Medicare / Medicaid certified nursing facilities immediately inspect all beds to identify areas of possible entrapment and take immediate action to reduce the risk of entrapment. ""In 1995, the U.S. Food and Drug Administration (FDA) issued a Safety Alert entitled 'Entrapment Hazards with Hospital Bed Side Rails' to several groups of health care providers, including all nursing homes and hospital administrators. In this Alert, the FDA made the following recommendation: 'Inspect all hospital bed frames, bed side rails, and mattresses as part of a regular maintenance program to identify areas of possible entrapment. Regardless of the mattress width, length, and/or depth, alignment to the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position...' ""The Alert also reminded providers of their responsibility under the Safe Medical Devices Act of 1990, which requires hospitals and other user facilities to report deaths, serious illness, and injuries associated with the use of medical devices, including bed rails."" -- The State survey and certification agency's 2005 Safety Alert also contained the following: ""In April 2003, the Hospital Bed Safety Workgroup published Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings. ""Suggested Bed Rail Safety Guidelines are as follows: "" 'If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient ' s assessed needs, or have been tried and were unsuccessful in meeting the patient ' s assessed needs, then close attention must be given to the design of the rail and the relationship between rails and other parts of the bed. 1. The bars within the bed rails should be closely spaced to prevent a patient ' s head from passing through the openings and becoming entrapped. 2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering. 3. Care should be taken that the mattress does not shrink over time or after cleaning. Such shrinkage increases the potential space between the rails and the mattress. 4. Check for compression of the mattress's outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail. 5. Ensure that the mattress is appropriately sized for the selected bed frame, as not all beds and mattresses are interchangeable. 6. The space between the bed rails and the mattress and the headboard and the mattress should be filled either by an added firm inlay or a mattress that creates an interface with the beds rail that prevents an individual from falling between the mattress and bed rails. 7. Latches securing bed rails should be stable so that the bed rails will not fall when shaken. 8. Older bed rail designs that have tapered or winged ends are not appropriate for use with patients assessed to be at risk for entrapment. 9. Maintenance and monitoring of the bed, mattress, and accessories such as patient / caregiver assist items should be ongoing.' "" --- c) In an interview, the director of nursing (DON - Employee #82) reported the [MEDICATION NAME] low air loss mattress manufacturer's operating manual identified that side rails must be used with this mattress. Employee #73 produced a copy of this operating manual to the survey team on 06/25/09. Review of the manual revealed: ""[MEDICATION NAME] mattresses are not intended to be AND DO NOT FUNCTION AS a patient fall safety device. SIDE RAILS MUST BE USED WITH THE [MEDICATION NAME] MATTRESS TO HELP PREVENT FALLS, unless determined unnecessary based on the facility protocol or the patient's medical needs as determined by the facility, IN THESE CASES THE USE OF OTHER SUITABLE PATIENT SAFETY MEASURES ARE RECOMMENDED."" The facility failed to complete individualized assessments for each resident using a [MEDICATION NAME] mattress to identify potential bed safety hazards and/or needs. .",2014-09-01
11051,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,309,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide the necessary care and services to each resident, to assist them in attaining or maintaining the highest practicable physical well-being, by failing to obtain physicians' orders to define the parameters of use of specialty mattresses and/or side rails and failing to carry out a physician's order reducing the dosage of a medication. This affected four (4) of twenty-eight (28) sampled residents. Resident identifiers: #84, #129, #114, and #15. Facility census: 128. Findings include: a) Resident #84 During the general tour of the facility at 2:30 p.m. on 06/22/09, observation found Resident #84 in bed resting on [MEDICATION NAME] low air loss mattress with controls that allowed for different settings of firmness. Review of her care plan revealed an intervention, under the problem of wound care, for: ""Pressure redistribution surfaces to bed."" However, there was no evidence in Resident #84's record of a physician's order for use of this mattress or of the settings to be used. During an interview at 1:15 p.m. on 06/25/09, the director of nursing (DON - Employee #82) acknowledged the facility failed to obtain a physician's order for use of the specialty mattress and assumed the nurses were using the same settings that were being used for other residents. b) Resident #129 Medical record review, on 06/25/09, revealed Resident #129 was using a [MEDICATION NAME] mattress (for an alteration in skin integrity) in conjunction with side rails. Further review revealed there was no physician's order for the mattress or the side rails, and the facility did not complete a bed safety assessment or a side rail use assessment prior to implementing these interventions. (See also citation at F272.) c) Resident #114 Observation, at 11:00 a.m. on 06/25/09, revealed this resident was lying on a low air mattress which had a raised border surrounding it. The resident also had raised half (1/2) side rails. Review of the resident's current physicians' orders revealed no order for this mattress or the side rails. Further review revealed the mattress (Stat 4000 Multizone Mattress coverlay with settings Float Mode: 4.0, 5.5, 6.0, 5.0,3.5, 1.5) had originally been ordered on [DATE], but the order had not been carried forward to the resident's current orders. d) Resident #15 Review of Resident #15's medical record, on 06/23/09, disclosed a ""Consultation Report"" completed by the facility's contracted pharmacist consultant. This document, dated as completed on 10/28/08, recommended to the physician that the continued use of Nerium 40 mg daily to exceed twelve (12) weeks should be accompanied by a documented rationale for continued use. The DON had written a message to the physician on the bottom of the form asking to change the dose of Nerium to 20 mg daily. On 11/28/08, the resident's attending physician addressed the recommendation by stating ""as below"". According to the DON, when questioned on 06/23/09 at 11:00 a.m., this statement indicated he would like to change the order to Nerium 20 mg daily. Further review of the resident's current medical regimen disclosed this order had never been carried out by facility staff. The resident continued to receive Nerium 40 mg daily. .",2014-09-01
11052,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,329,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of medication formularies, and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #35 was given a hypnotic (Ambien) without an assessment of possible causes for the sleeplessness and without first attempting the use of non-pharmacologic interventions to reduce or prevent the target behaviors prior to medicating the resident. Resident identifiers: #35. Facility census: 128. Findings include: a) Resident #35 1. Medical record review, on 06/23/09, revealed the physician [MEDICATION NAME](an hypnotic) on 03/10/09. Review of the nursing progress for 03/10/09 found documentation to indicate Resident #35 had exhibited increased agitation and was not sleeping at night. Further record review failed find when these behaviors were initially observed, nor did the record contain any assessments in an attempt to identify possible causal or contributing factors to the increased agitation and decreased ability to sleep at night. Additionally, the medical record contained no evidence of any non-pharmacologic interventions that had been attempted without success to reduce or prevent the agitation and difficulty sleeping, prior to institution of the hypnotic (Ambien). 2. According to http://www.rxlist.com/ambien-drug.htm: ""Ambien ([MEDICATION NAME]) is indicated for the short-term treatment of [REDACTED].[MEDICATION NAME] been shown to decrease sleep latency for up to 35 days in controlled clinical studies. This medication is usually limited to short-term treatment periods of 1-2 weeks or less. ""Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of [REDACTED]. The failure of [MEDICAL CONDITION] to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. ""Use in the elderly and/or debilitated patients: Impaired motor and/or cognitive performance after repeated exposure or unusual sensitivity to sedative/hypnotic drugs is a concern in the treatment of [REDACTED]. Therefore, the [MEDICATION NAME] is 5 mg in such patients to decrease the possibility of side effects. These patients should be closely monitored."" 3. On 06/25/09, the director of nursing (DON - Employee #82), when interviewed concerning this resident, identified the facility had been providing education to nursing staff on other psychoactive medications, but they needed to take a closer look at the use of hypnotics in relationship to non-pharmacologic interventions tried prior to initiation of medications. .",2014-09-01
11053,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,502,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's lab monitoring protocol, and staff interview, the facility failed to obtain routine lab studies for one (1) of twenty-five (25) sampled residents with a [DIAGNOSES REDACTED].#35. Facility census: 128. Findings include: a) Resident #35 Medical record review, on 06/23/09, revealed Resident #35 was a diabetic. Review of the laboratory testing completed revealed a Hemoglobin A1c completed in November 2008. According to the facility's lab monitoring protocol for diabetic therapy, Hemoglobin A1c is to be completed every four (4) months. Review of the resident's monthly recapitulation of physician orders [REDACTED]. On the afternoon of 06/25/09, the facility's director of nursing (DON - Employee #82), when interviewed, identified this resident had been in and out of the hospital during this period and the Hemoglobin A1c could have been due when she was in the hospital. Prior to survey exit, no additional information was provided regarding this concern. .",2014-09-01
11054,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,386,E,0,1,OJEL11,"Based on medical record review and staff interview, the facility failed to ensure the attending physician, for four (4) of twenty-eight (28) sampled residents, reviewed the resident's total plan of care with each assessment visit by signing routine and telephone orders. Resident identifiers: #15, #35, #19, and #4. Facility census: 128. Findings include: a) Resident #15 The medical record of Resident #15, when reviewed on 06/23/09, disclosed the resident's attending physician wrote a progress note describing a regular assessment visit for this resident on 05/29/09. Further review disclosed the physician had failed to sign telephone orders given to facility staff on 01/10/09, 01/29/09, 04/03/09, 04/08/09, 04/15/09, 04/24/09, 04/28/09, 05/06/09, 05/08/09, and 05/12/09. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/23/09 at 11:00 a.m., and she confirmed the physician should have signed and dated these outstanding orders. b) Resident #35 Medical record review, completed on 06/23/09, revealed the physician was in the facility and saw Resident #35 on 06/19/09. Further record review revealed telephone orders received prior to this visit which the physician did not sign, which had been given on 06/03/09, 06/08/09, 06/13/09, and 06/15/09. On the afternoon of 06/25/09, the DON, when interviewed, identified the physician recently came to her and told her he thought he was caught up with all documentation. The DON acknowledged at this time he must not be caught up with all the documentation. c) Resident #19 A review of the clinical record revealed verbal orders from the physician of Resident #19, given on 05/19/09, had not been signed by the physician as of 06/24/09, although he had visited the resident and had written a progress note on 06/05/09. During an interview with the administrator at 10:30 a.m. on 06/25/09, he acknowledged it appeared the physician had overlooked some of the orders. d) Resident #4 This resident had ten (10) telephone orders which had not been signed when the physician made his last visit on 06/22/09. These telephone orders were dated 05/23/09, 05/24/09, 05/27/09, 06/02/09, 06/03/09 (two (2) orders), 06/04/09, 06/07/09, 06/12/09, and 06/16/09. .",2014-09-01
11055,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,225,D,0,1,OJEL11,"Based on record review and staff interview, the facility failed to screen one (1) of nine (9) sampled employees (Employee #133) prior to hire, to ensure the individual had no findings that would indicate unfitness for service. Employee #133, a registered nurse (RN), indicated having licensure and prior work history in the State of Maryland. The facility failed to contact the Maryland RN licensing board to ensure Employee #133's RN license was not impaired. Facility census: 128. Findings include: a) Employee #133 A review of the personnel file of Employee #133 revealed she was hired as a RN on 04/06/09. Her written application indicated she was also licensed and had been employed in the State of Maryland. There was no evidence in her personnel file to indicate the facility verified the were no negative findings associated with Employee #133's RN licensed in Maryland. This was verified by the administrator at 10:45 a.m. on 06/25/09, who reported he was unaware of the need to verify the status of out-of-state professional licenses. .",2014-09-01
11056,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,247,D,0,1,OJEL11,"Based on record review and staff interview, the facility failed to notify the resident or the responsible party prior to transferring the resident to another room. This affected one (1) of twenty-eight (28) sampled residents. Resident identifier: #84. Facility census: 128. Findings include: a) Resident #84 A review of the clinical record revealed Resident #84 had been determined to lack capacity to understand and make health care decisions, although she was alert, able to communicate, and able to make her needs known, as documented in nursing notes on 06/19/09. Her son was serving as her health care surrogate. She was transferred from a room on 200 Wing to a room on 300 Wing. However, there was no documentation in the medical record to indicate that either she or her son was consulted prior to the room change. The nursing notes, at 10:45 a.m. on 06/18/09, recorded, when the son called to question the transfer, ""Informed was moved d/t (due/to) bed needs."" During an interview with the director of nursing (DON - Employee #82) at 9:30 a.m. on 06/25/09, she reviewed the record and expressed surprise that prior notice was not documented. .",2014-09-01
11057,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,285,B,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of applicants for admission were screened, in accordance with the Pre-Admission Screening and Resident Review (PASRR) program, prior to admission to the facility for three (3) of twenty-eight (28) sampled residents. Resident identifiers: #19, #74, and #113. Facility census: 128. Findings include: a) Resident #19 A review of the clinical record revealed Resident #19 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 04/10/09, as indicated by the dated signature in Section V. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he acknowledged this determination was made after the resident's admission to the facility. b) Resident #74 A review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 01/12/09, as indicated by the dated signature in Section V. During an interview with the social worker at 11:00 a.m. on 06/24/09, he acknowledged the determination was made after the resident's admission to the facility. c) Resident #113 The medical record of Resident #113, when reviewed on 06/23/09, disclosed the resident was admitted to the facility on [DATE]. Further review disclosed, at Item 42 on page 6 of the PASRR form, that a determination with respect to a Level II evaluation was not made until 03/25/09, after the resident's admission to the facility. .",2014-09-01
11058,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,315,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure one (1) of five (5) sampled residents with indwelling Foley urinary catheters had a valid physician's orders [REDACTED]. Resident identifier: #19. Facility census: 128. Findings include: a) Resident #19 A review of the medical record revealed Resident #19 was admitted to the facility from the hospital on [DATE], with an indwelling urinary catheter in place. The catheter was discontinued per physician's orders [REDACTED]. Resident #19 was readmitted to the facility on [DATE], with the catheter in place. There was no evidence of a physician's orders [REDACTED]. The resident was observed to have a urinary catheter in place at 2:00 p.m. on 06/22/09, while the resident's wife was being interviewed. This was confirmed by the director of nursing (DON - Employee #82) at 10:30 a.m. on 06/24/09, although she stated she had no explanation for the catheter's use in the absence of an order. .",2014-09-01
11059,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,441,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the effectiveness of the infection control program by allowing two (2) of nine (9) employees to care for residents without an annual screening for [DIAGNOSES REDACTED] (TB). This has the potential to effect all residents. Employee identifiers: #124 and #155. Facility census: 128. Findings include: a) Employee #124 A review of the employee health file for Employee #124, a licensed practical nurse, revealed her most recent TB screening was in 2006. b) Employee #155 A review of the employee health file for Employee #155, a licensed practical nurse, revealed her most recent TB screening was dated 01/06/08. c) During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee health had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show these employees had received their TB annual screening. .",2014-09-01
11060,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,492,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, the facility failed to provide information regarding Hospice to one (1) resident from a total sample of twenty-five (25), who recently received orders for ""comfort measures only"". This is required by W.V.C. 16-5C-20. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 Medical record review, on 06/24/09, revealed this resident's Physician order [REDACTED]. Further review revealed no evidence the resident and family had been provided information regarding Hospice. Interview with the social worker, on the morning of 06/24/09, verified this information had not been provided as required. --- Part II -- Based on review of personnel files and staff interview, the facility failed to provide one (1) of three (3) certified nursing assistants, hired in 2009, with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. Employee identifier: #75. Facility census: 128. Findings include: a) Employee #75 A review of the personnel file of Employee #75, a nursing assistant who was hired on 06/08/09, failed to reveal any evidence that the facility had provided this employee with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee records had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show this employee had received the required information. .",2014-09-01
11061,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,241,D,0,1,OJEL11,"Based on observation and staff interview, the facility's staff failed to provide care to residents in a manner that maintains and/or enhances each resident's self-esteem and self-worth, by failing to respond in a timely manner to a resident's request for assistance. Four (4) staff members were randomly observed to pass by (and not answer) an activated resident call light on the 100 Wing of the facility. Resident identifier: #29. Facility census: 128. Findings include: a) Resident #29 At 11:35 a.m. on 06/24/09, a staff member (Employee #116) was observed to pass by a resident-activated call light in a room on the 100 Wing of the facility. The employee was approached by this surveyor and, when asked if all staff was responsible for answering call lights, she stated, ""Yes."" It was pointed out to her that she had just passed by one without responding. She stated she had not noticed it, and she returned to the room occupied by Resident #29 and answered the light, turning it off. The call light was re-activated almost immediately, and at 11:40 a.m., three (3) additional staff members were observed to walk past the light, not responding. One (1) of the three (3) employees (Employee #161) was approached and asked who was responsible for answering call lights. Employee #161 responded, ""Everyone."" When informed that she and her co-workers had just failed to answer the light to Resident #29's room, Employee #161 stated that she had not noticed it was ringing. .",2014-09-01
11062,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,280,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed, for two (2) of twenty-five (25) residents sampled, to update the plan of care to reflect current needs. This included care received at an outside wound care clinic for one (1) resident and the use of a specialized air flow mattress for one (1) resident. Resident identifiers: #40 and #114. Facility census: 128. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 06/23/09, disclosed the resident had acquired a Stage IV pressure ulcer during a hospitalization from which he was re-admitted to the facility on [DATE]. Shortly thereafter, the resident had begun weekly visits to and received treatments at an area wound care clinic. The resident's plan of care was reviewed. Although the plan did have interventions related to the resident's skin condition and care provided, the information was not correct at this time and did not mention the resident's weekly wound care clinic visits. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/25/09, and no further information was available related to the a lack of revision to this resident's care plan. b) Resident #114 Observation, at 11:00 a.m. on 06/25/09, found this resident lying on a low air mattress with a raised border surrounding it. The mattress was a Stat 4000 Multizone Mattress which had a ""coverlay"" and required specific air flow settings. Review of the resident's care plan revealed the mattress was not currently identified on the care plan and had not been added to the care plan when its use was initiated on 05/20/09. .",2014-09-01
11063,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,281,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's ""Do Not Crush"" document, the facility failed to ensure one (1) of five (5) nurses administered medications in accordance with current professional standards of quality, by crushing and administering a medication that was noted to be in a form that should not be crushed. Resident identifier: #31. Facility census: 128. Findings include: a) Resident #31 A nurse (Employee #163) was observed performing medication administration at 8:35 a.m. on 06/24/09. This employee was noted to crush the medications she was preparing for Resident #31, which included [MEDICATION NAME], Vitamin D, [MEDICATION NAME], Sodium [MEDICATION NAME], and [MEDICATION NAME]. All of the medications were crushed with the exception of the [MEDICATION NAME], which Employee #163 stated the resident could swallow whole. Following the administration of the medication, the facility's ""Do not crush"" list available for nurse reference was requested and received from the facility's director of nursing (DON - Employee #82). Review of this document disclosed the medication [MEDICATION NAME] was a slow release medication and should not be crushed. The DON confirmed the findings when this information was provided at approximately 10:00 a.m. on 06/24/09. .",2014-09-01
11064,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,514,E,0,1,OJEL11,"Based on medical record review and staff interview, the facility staff failed to maintain resident medical records in accordance with accepted professional standards, by failing to ensure all documents in the record displayed a date of entry for two (2) of twenty-five (25) sampled residents. Resident identifiers: #15 and #113. Facility census: 128. Findings include: a) Residents #15 and #113 The medical records for Residents #15 and #113, when reviewed on 06/23/09, disclosed on both records documentation on a ""Progress Note"" form with a signature that appeared to be a large ""R"". The documents were also signed by the resident's attending physician. The information contained on the forms was a recapitulation of each resident's condition, including weight, medications, etc. The forms displayed no date to indicate when they were written and placed in the residents' records. The facility's director of nursing (DON - Employee #82), when questioned about these forms and documentation on 06/23/09 at 11:00 a.m., stated these forms were completed by the facility's restorative nurse. The DON confirmed the lack of a date to indicate when these entries were written.",2014-09-01
11065,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,364,F,0,1,OJEL11,"Based on observation, food temperature measurements, the confidential resident group interview, the facility's resident council meeting minutes, and staff interview, it was determined the facility failed to assure foods were attractive for residents on pureed diets, failed to assure hot foods were hot upon receipt by the resident, and failed to assure staff intervened when food were not hot enough. This practice had the potential to affect all facility residents who received nutrition from the dietary department. Facility census: 128. Findings include: a) Observation of the pureed foods, for the noon meal on 06/24/09, revealed all the foods were pale in color. When asked what the garnish was, the dietary manager (DM) stated the menu did not call for garnishes for pureed meals. After discussion, the pureed foods were garnished with parsley flakes, and a pureed apple slice was added to each plate. Dietary staff stated the food was much more attractive with the garnishes. b) Review of the past three (3) months of the facility's resident council meeting minutes revealed residents expressed concern regarding cold foods on 03/24/09. During the confidential group interview held with the residents at 1:45 p.m. on 06/23/09, five (5) of seven (7) responding residents stated that hot foods were not hot when they received them. During that meeting, residents also reported staff never offered to heat their meals for them. The residents said if they asked, staff would do this for them, but no offer was ever made. Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. Observations were made of tray delivery on the 100 hall, on 06/24/09. The cart arrived at 12:10 p.m. At 12:40 p.m., four (4) residents had not yet been served their meal. At 12:40 p.m., two (2) of these residents were served. The observation ended at 12:55 p.m., and the last two (2) residents had not yet been served their meal. .",2014-09-01
11066,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,363,E,0,1,OJEL11,"Based on menu review, observation, and staff interview, the facility failed to ensure menus were followed for residents ordered consistent carbohydrate (CC) and renal diets. This practice affected twelve (12) residents ordered CC diets, and had the potential to affect one resident who was ordered a renal diet. Facility census: 128. Findings include: a) Menu review revealed that residents on CC and renal diets were to receive cubed steak instead of a sausage / egg / cheese puff on 06/24/09. b) Observation of the service of the noon meal, on 06/25/09, revealed there was no cubed steak prepared. Residents on CC diets were served the sausage / egg / cheese puff. c) This was brought to the attention of the dietary manager (DM) during the meal service. At that time, she asked the cook if cubed steak had been prepared for these diets. The cook stated she did not notice that on the menu. At that time, the renal diet had not yet been served; therefore, the DM intervened, and the resident ordered a renal diet did not receive a sausage / egg / cheese puff. .",2014-09-01
11067,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,371,F,0,1,OJEL11,"Based on observation and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 128. Findings include: a) During the initial observation of the dietary department at 3:10 p.m. on 06/22/09, the following sanitation infractions were identified: 1. A staff member was using a container of filled with water to clean. When the water was tested , there was no sanitizing agent in the water. 2. A greasy substance was noted under the shelf at the food preparation sink. 3. Carrots from the previous meal were observed in the steam table water. 4. A large trash barrel had a large round hole cut in the lid. This practice caused the container to be an uncovered trash container in the kitchen. 5. One (1) male dietary employee did not have his mustache and beard covered to assure hairs did not fall into foods and/or onto food service items. Additionally, the female dietary personnel had loose hair outside of their hairnets. 6. Cakes were stored in the dry storage room. They were not covered to prevent possible contamination as staff went in and out of that room. 7. Steam table pans had not been fully air dried prior to stacking inside of each other, and these pans had crusty substances which could be scraped off with a fingernail, as well as a greasy debris on them. b) Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. To prevent the rapid growth of toxic microorganisms, which contribute to food borne illnesses, foods must be held for service at 135 degrees F or above. .",2014-09-01
11068,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,323,E,0,1,OJEL11,"Based on observation, staff interview, and medical record review, the facility failed to assure one (1) of one (1) resident's side rail padding was applied correctly, and failed to assure an electrical cover was properly secured flush to the floor so as not to present a trip hazard. These practices had the potential to result in injury to the resident with the side rails, and in injury to any resident who was ambulating near the kitchen entrance. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 During the initial tour at 2:30 p.m. on 06/22/09, this resident was observed lying in bed with a device between each of the side rails and the resident. The devices had slid down and were not fully covering the side rails. On 06/24/09 at 10:00 a.m., this resident was observed with a nursing assistant (NA) present. Upon inquiry, the NA stated the devices were to protect the resident, because he often leaned his face into the side rails. At that time, the NA noted the devices had slid down, exposing the side rails. The NA then repositioned the devices. During the afternoon of 06/25/09, the resident was again observed with the director of nursing (DON - Employee #82) present. When shown the devices, which again had slid off the side rails, the DON stated the devices were not properly applied. At that time, the DON demonstrated how the devices were supposed to be applied. They were supposed to be affixed with Velcro, which was a part of each device. When applied correctly, the safety devices remained in place and protected the resident from the side rails. b) Observation, on 06/23/09 at 10:00 a.m. and 06/24/09 during the early afternoon, revealed a metal electrical cover attached to the floor, in the hallway near the kitchen. This cover was not flush with the floor and created a trip hazard. Residents were observed ambulating in this area throughout each day of the survey. .",2014-09-01
11069,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,280,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise an interdisciplinary care plan after a minimum data set (MDS) assessment revealed Resident #40 had not had a bowel movement for at least seven (7) days. There was no evidence this resident's constipation was addressed after it was identified through the assessment process, to assure interventions were implemented to alleviate this resident's constipation. This resident experienced a total of twelve (12) days without having a bowel movement and no interventions were initiated. This was found to be true for one (1) of six (6) sampled residents. Resident identifier: #40. Facility census: 73. Findings include: a) Resident #40 Review of Resident #40's medical record revealed a Medicare 14-Day MDS, with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated because either the resident had an ostomy or the resident did not have a bowel movement for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, but not a [MEDICAL CONDITION]). The record also indicated her last recorded bowel movement occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month (a total of eight (8) days). The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no BM. The medication administration records (MARs) for both April and May 2011, when reviewed, found no evidence this resident had received a laxative or any type of medication for constipation at any time during these two (2) months. The nursing notes for Resident #40 contained no mention of any issues with constipation or any acknowledgement that she had not been having BMs. During an interview with a registered nurse assessment coordinator (RNAC - Employee #73) on 05/04/11 at 10:50 a.m., she verified she completed the MDS for Resident #40. She stated she encoded this MDS item as ""9"", because there was no evidence this resident had a BM for the 7-day assessment reference period. When questioned as to what actions she took after identifying the resident had had no BM during the 7-day assessment reference period, she stated she always tells the nurse on the hall when a resident has not had a BM, but she could not remember which nurse she told. She confirmed she had not documented having to told the nurse this anywhere, and she verified that the last BM this resident had recorded in her medical record (as of this date - 05/04/11) was on 04/22/11. There was no evidence this issue had been addressed in the resident's care plan or that any interventions had been initiated after the RNAC identified the resident was experiencing problems with constipation. .",2014-09-01
11070,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,309,G,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to provide care and services necessary to maintain a resident's highest practicable physical well-being, including adequate assessment, monitoring, and/or prompt intervention in response to the identification of abnormal findings on a resident assessment instrument. On 04/22/11, Resident #40 was noted to have had two (2) bowel movements; however, staff failed to identify that Resident #40 did not have a bowel movement for three (3) consecutive days thereafter, and failed to implement to facility's Bowel Protocol, which indicated staff was to administer milk of magnesia (MOM) if a resident has had no BM after three (3) days. The facility's registered nurse assessment coordinator (RNAC) later identified, on a resident assessment instrument, that Resident #40 had not had a BM during a 7-day assessment reference period ending on 04/30/11. (This was unusual for her, as the resident's bowel elimination pattern had previously identified she had BMs every other day.) However, staff did not intervene by collecting information about her physical health status and/or by initiating the physician's standing order for constipation at that time. On 05/04/11, after the nurse surveyor questioned staff about the resident's lack of BMs for a period of twelve (12) days, staff administered the first step of the facility's Bowel Protocol, a 30 cc dose of MOM (which was to be given after a resident had no BM for three (3) days), without completing a physical assessment of the resident. When a physical assessment of the resident was completed at the nurse surveyor's request, the resident moaned, stating, ""My stomach hurts."" Resident #40 continued to moan and had a look of discomfort on her face. Staff later administered an enema, after which the resident expelled an extra large BM. The deficient practice resulted in actual harm to one (1) of six (6) sampled residents and has the potential to result in harm to more than an isolated number of the facility's residents. Facility census: 73. Findings include: a) Resident #40 1. Record review, on 05/04/11, revealed Resident #40, who had been admitted to the facility on [DATE], had a bowel retraining assessment dated [DATE], which identified her usual bowel elimination pattern as having a BM every other day. This assessment also revealed she did not have a history of constipation. Review of Resident #40's interdisciplinary care plan, dated 04/25/11, found this resident was identified as being at risk for gastrointestinal symptoms or complications related to the use of a gastrostomy tube ([DEVICE]). The interventions associated with this problem included: ""Assess for and report signs and symptoms of nausea / vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds, and abdominal pain."" Another intervention stated: ""Monitor and record bowel movements."" These were the only interventions in the care plan related to this resident's bowel elimination. Review of Resident #40's medical record revealed a Medicare 14-Day MDS, with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated, because either the resident had an ostomy or the resident did not have a BM for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, not a [MEDICAL CONDITION] or other bowel diversion). The record also indicated her last recorded BM occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month - a total of eight (8) days. The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no bowel movement. The medication administration records (MARs) for both April and May 2011, when reviewed, found no evidence this resident had received a laxative or any type of medication for constipation at any time during these two (2) months. The nursing notes for Resident #40 contained no mention of any issues with constipation or any acknowledgement that she had not been having BMs. -- 2. During an interview with the RNAC (Employee #73) on 05/04/11 at 10:50 a.m., she verified she completed the above-mentioned MDS for Resident #40. She stated she encoded this MDS item as ""9"", because there was no evidence this resident had a BM for the 7-day assessment reference period. When questioned as to what actions she took after identifying the resident had had no BM during the 7-day assessment reference period, she stated she always tells the nurse on the hall when a resident has not had a BM, but she could not remember which nurse she told. She confirmed she had not documented having to told the nurse this anywhere, and she verified that the last BM this resident had recorded in her medical record (as of this date - 05/04/11) was on 04/22/11. -- 3. During an interview on the morning of 05/04/11, the nurse assigned to care for Resident #40 (a licensed practical nurse (LPN - Employee #3)) was questioned about the facility's process for identifying residents who were experiencing constipation and how the nurses were made aware of the need to further assess residents for constipation. She stated the clerk at the desk reviews the books containing the BM records and lets the nurses know if the residents need something, or sometimes the nursing assistants let them know. She said the nurses used to check the books, but they don't any more. When questioned about Resident #40, Employee #3 stated she was not aware the resident had not had a BM, because no one had said anything to her. When asked about the facility's bowel protocol, Employee #3 stated that, if a resident has not had a BM in three (3) days, they give 30 cc of MOM. If the resident does not have a BM within eight (8) hours after receiving the MOM, they give the resident a suppository ([MEDICATION NAME] rectal suppository). If the resident does not have a BM within eight (8) more hours, they notify the doctor. -- 4. An interview was conducted with the RN unit manager (Employee #83) at 11:45 a.m. on 05/04/11. She stated that, if constipation had been identified for Resident #40, the interventions should be recorded on the MAR. She stated the nursing assistants record the residents' BMs on the ADL flow sheets, then they report to the nurse or the unit manager. She stated the MDS nurses also bring this to their attention. When asked if anyone else monitors this, she said not that she is aware of. She stated the facility's Bowel Protocol is in front of every MAR book. She stated if this protocol is initiated, the nurses pass it on during report at shift change. -- 5. A nurse administered MOM to Resident #40 at 3:15 p.m. on 05/04/11. However, review of the resident's medical record found no evidence that a physical assessment had been completed on the resident. Employee #83 was asked to complete a physical assessment of Resident #40 with this nurse surveyor present. The resident was in bed at that time. Employee #83 told the resident what she was going to do. The nurse listened to her bowels and reported that bowel sounds were present. As she touched the resident's abdomen with her stethoscope, the resident started moaning. The nurse then felt her stomach, and the resident was moaning, stating, ""My stomach hurts."" Resident #40 continued to moan and had a look of discomfort on her face. Employee #83 asked Resident #40 if she had a BM today, and the resident answered, ""No."" Employee #83 then asked if her bowels moved yesterday, and she again said, ""No."" The resident told the nurse, ""I thought they were going to move, but they didn't."" -- 6. The director of nursing (DON - Employee #76) was notified, on 05/04/11 at 3:30 p.m., of these observations, including the resident's moaning and complaints of stomach pain when assessed. The DON was also made aware of the resident having had no BMs for the preceding twelve (12) days. She responded that she reviewed the resident's medical record and saw that she had complained of stomach pain when she came in. This nurse surveyor told the DON that, according to the resident's MAR, Resident #40 had received a dose of MOM. However, the facility's Bowel Protocol indicated that MOM was to be given when a resident has had no BM in three (3) days, and Resident #40 had had no BM in twelve (12) days. The nurse surveyor asked the DON to have someone notify the physician of Resident #40's condition. The DON returned at 4:00 p.m. and informed this nurse surveyor that the nurses gave Resident #40 an enema, and she had extra large results. .",2014-09-01
11071,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,322,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure staff implemented appropriate measures to prevent complications from occurring for residents with gastrostomy tubes ([DEVICE]s). Two (2) of three (3) residents with [DEVICE]s were observed to not receive appropriate services to prevent complications from occurring. Observation found Resident #40, who had [DEVICE], lying with her bed in a flat position (head of bed not elevated) fifteen (15) minutes after her enteral feeding had ended. Review of her physician's orders [REDACTED]. Additionally, this resident, who was not to receive anything by mouth, was observed with a glass of chocolate milk, and the facility had not been monitoring her bowel elimination as directed in her care plan to address her new [DEVICE]. Resident #7, who also had a [DEVICE], was also observed to be in a flat position without her head elevated while her feeding was infusing, placing her at risk for aspiration. Resident identifiers: #40 and #7. Facility census: 73. Findings include: a) Resident #40 1. During an observation of Resident #40 on 05/03/11 at 11:15 a.m., she was sitting up in her wheelchair beside of her bed, and her [DEVICE] feeding of [MEDICATION NAME] 1.2 was infusing at a rate of 60 cc / hour at that time. The resident was again observed at 11:45 a.m., at which time her feeding pump was turned off and she was lying in her low bed with mats on the floor. The head of her bed was flat (not elevated) at the time of this observation. Review of her physician's orders [REDACTED]. - 2. Further review revealed an order, written on 04/20/11, for her status to be NPO (nothing by mouth). She had a [DIAGNOSES REDACTED]. Review of the facility's incident / accident reports found a report, dated 04/22/11, stating this resident had consumed a portion of a meal tray that had been left in her room for another resident. Documentation on the reported noted her NPO status; she was assessed and did not have complications from that occurrence. Observation, on 05/04/11 at 12:15 p.m., found Resident #40 sitting in her wheelchair with a glass of chocolate milk in front of her. This nurse surveyor questioned the nurse on the hall (Employee #73) if this resident was allowed to have that chocolate milk. She verified, by reviewing the physician's orders [REDACTED]. She took it out of the resident's room. - 3. Review of Resident #40's interdisciplinary care plan, dated 04/25/11, found this resident was identified as being at risk for gastrointestinal symptoms or complications related to the use of a gastrostomy tube ([DEVICE]). The interventions associated with this problem included: ""Assess for and report signs and symptoms of nausea / vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds, and abdominal pain."" Another intervention stated: ""Monitor and record bowel movements."" Review of Resident #40's medical record revealed a Medicare 14-Day minimum data set (MDS), with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated, because either the resident had an ostomy or the resident did not have a bowel movement (BM) for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, not a [MEDICAL CONDITION] or other bowel diversion). The record also indicated her last recorded BM occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month - a total of eight (8) days. The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no bowel movement (from 04/23/11 to 05/04/11). There was no evidence that any interventions to address constipation had been initiated during this time or that anyone had further assessed the resident's health status and reported the lack of BMs to the resident's physician, as stated in her care plan to prevent complications related to the [DEVICE]. - 4. The registered nurse (RN) unit manager (Employee #83) was notified, on 05/04/11 at 3:10 p.m., of the above findings and concerns with respect to the [DEVICE] feeding, including the resident's positioning not being maintained after she had her feeding as ordered, the resident's NPO status not being maintained, and the failure to monitor BMs as stated in the care plan. -- b) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. .",2014-09-01
11072,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,281,E,1,0,4R4011,". Based on observation, staff interview, record review, a review of the facility's policy procedures on medication administration times, and the facilities competency testing, the facility failed to provide services according to their policy and to meet professional standards of clinical practice. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 73. Findings include: a) The medication pass was observed randomly throughout three (3) days of the complaint investigation. Entrance to the facility was on 05/02/11 at 10:15 a.m. Two medication passes were being performed by two (2) licensed practical nurses at the time of entrance. The medications for the one hundred (100) hall (Employee #74) and three hundred (300) Hall (Employee #69) were scheduled to be given at 9 a.m. During the observation on 05/02/11 the one hundred (100) hall was completed at 11:55 a.m. and the three hundred hall (300) was completed at 11:35 a.m. The medication pass should have been completed by 10:00 a.m. according to the facility's policy and in order to meet the professional standards of clinical practice. Further review of the Medication Administration Record [REDACTED]. This finding was discussed with the director of nursing (employee #76) and the nurse passing the medications (Employee #74) at 1:10 p.m. on 05/02/11. The facility's medication administration times policy and the nursing competency testing was reviewed on 05/03/11. According to the medication administration times policy the medication administration pass may begin sixty (60) minutes before the designated times of administration, but may not exceed sixty (60) minutes after the designated times of administration. On 05/03/11 at 9:40 a.m. the licensed practical nurse for (400) hall was observed just beginning her medication pass. On 05/03/11 at 9:40 a.m. (Employee #3) stated, ""I thought I would start with this hall first."" Review of the facility's medication administration times revealed that the 400 Hall is scheduled to begin at 8:00 a.m. During the observation of the medication pass on 05/04/11 (Employee #48) was passing the medications for the two hundred (200) hall and completed her medication pass at 10:10 a.m. The one hundred (100) hall was completed at 11:00 a.m. by (Employee #74). The RN unit managers were asked by this surveyor how they monitor the nurses on the floor. On 05/04/11 at 9:10 a.m. during an interview with the RN unit manager (Employee #83), she stated, ""I monitor the interactions with the nurses and the residents, I also monitor timeliness of the medication pass."" Employee #83 further stated that she is at the medication cart at least eight (8) times per day. When this surveyor informed Employee #83 the timeliness of the medication passes observed, she proceeded to assist Employee #3 with her medication pass. Employee # 62 was asked the same question related to monitoring the nurses on the floor she stated, ""I try to monitor timeliness of the medication pass."" Observations of the medication pass were discussed on the afternoon of 05/03/11 and again on 05/04/11 with the director of nursing (Employee #76) and the nurses conducting the medication passes (Employee #74), and (Employee #3). .",2014-09-01
11073,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,282,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, policy review, and record review, the facility failed to provide care in accordance with a resident's written care plan. During a 3-day complaint investigation, observation found one (1) of three (3) residents who received enteral feedings via a gastrostomy tube ([DEVICE]) lying flat with the head of the bed not elevated in accordance with interventions identified in the resident's care plan intended to prevent aspiration. Resident identifier: #7. Facility census: 73. Findings include: a) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. .",2014-09-01
11074,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,323,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to provide an environment that was as free as possible from accident hazards, for two (2) of three (3) residents with gastrostomy tubes ([DEVICE]s) who did not receive care and services to prevent aspiration. Resident identifiers: #7 and #40. Facility census: 73. Findings include: a) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. -- b) Resident #40 1. During an observation of Resident #40 on 05/03/11 at 11:15 a.m., she was sitting up in her wheelchair beside of her bed, and her [DEVICE] feeding of Jevity 1.2 was infusing at a rate of 60 cc / hour at that time. The resident was again observed at 11:45 a.m., at which time her feeding pump was turned off and she was lying in her low bed with mats on the floor. The head of her bed was flat (not elevated) at the time of this observation. Review of her physician's orders [REDACTED]. - 2. Further review revealed an order, written on 04/20/11, for her status to be NPO (nothing by mouth). She had a [DIAGNOSES REDACTED]. Review of the facility's incident / accident reports found a report, dated 04/22/11, stating this resident had consumed a portion of a meal tray that had been left in her room for another resident. Documentation on the reported noted her NPO status; she was assessed and did not have complications from that occurrence. Observation, on 05/04/11 at 12:15 p.m., found Resident #40 sitting in her wheelchair with a glass of chocolate milk in front of her. This nurse surveyor questioned the nurse on the hall (Employee #73) if this resident was allowed to have that chocolate milk. She verified, by reviewing the physician's orders [REDACTED]. She took it out of the resident's room.",2014-09-01
11075,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,241,D,0,1,CKVD11,"Based on observation and staff interview, the facility did not assure residents with lap buddies were given the opportunity to dine in dignity in the community dining area free from restrictive devices while being directly supervised. This was evident for three (3) of fifteen (15) sampled residents. Resident identifiers: #13, #62, and #51. Facility census: 89. Findings include: a) Resident #13 On 06/02/09 at 8:55 a.m., observation found Resident #13 eating at the dining room table while sitting in her wheelchair with a lap buddy attached. Interview with Employee #17 revealed this resident always had on the lap buddy on while she ate. On 06/03/09 at 4:00 p.m., Employee #17 clarified, after checking with her supervisor, and reported Resident #13 was not supposed to use the lap buddy while dining. Employee #17 said this must have been an oversight. b) Resident #62 On 06/02/09 at 12:30 p.m., observation found Resident #62 sitting at the dining room table in her wheelchair with a lap buddy attached. Two (2) nursing assistants were setting up the lunch tray, which was on the dining room table in front of the resident. The lap buddy was not removed until surveyor intervention. c) Resident #51 On 06/02/09 at 12:30 p.m., observation found Resident #51 sitting at the dining room table in her wheelchair with a lap buddy attached. Two (2) nursing assistants were setting up the lunch tray, which was on the dining room table in front of the resident. The lap buddy was not removed until surveyor intervention. d) Review of the care plans for Residents #13, #62, and #51 found no documentation regarding removing the lap buddies while in the facility's dining room under supervision. These findings were reported to the director of nursing on 06/03/09 prior to leaving the facility at 5:00 p.m. .",2014-09-01
11076,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,279,E,0,1,CKVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident interview, and staff interview, the facility failed to develop comprehensive care plans to address the individualized needs of four (4) of fifteen (15) sampled residents. Resident identifiers: #13, #51, #62, and #68. Facility census: 89. Findings include: a) Resident #68 Resident #68, when interviewed on 06/02/09 at 1:30 p.m. and on 06/03/09 at 3:00 p.m., reported he had a stroke approximately six (6) years ago resulting in [MEDICAL CONDITION]. The resident was divorced and rarely received any visitors. He had a fall resulting in a [MEDICAL CONDITION] in April 2009 and was admitted to the facility for rehabilitative therapy services. The resident reported his life work was sports, having been a sports writer for a newspaper and a golf coach, and his primary interest was in sports, but the facility did not provide any activities relating to his interest in sports. The resident's activity assessment, dated 05/12/09, identified the resident had been a golf coach and sports writer. Review of Resident #68's medical record, on 06/04/09 at 10:00 a.m., found the resident's current plan of care, dated 05/30/09, did not address specific activity / social needs, likes, and/or interest for this [AGE] year old blind resident. When interviewed on 06/04/09 at 11:00 a.m., the registered nurse care plan coordinator (Employee #107) was unable to produce any additional evidence that the care plan addressed this resident's social needs and sports interest. b) Resident #13 Review of Resident #13's care plan revealed a goal indicating she will participate in an activity of choice three (3) times weekly. Two (2) interventions were listed to meet this goal - to encourage the resident to make decisions such as which activity to attend daily and to invite and take the resident to activities she may enjoy daily. However, the care plan did not identify any specific activities Resident #13 enjoyed and could do. Review of her participation record in activities for May 2009 revealed she attended some church services, pre-meal activities in the dining room, exercise with the rhythm band, and received one-on-one visits daily from staff of the activities department and visits from family and friends. Interview with the activity director (Employee #64), on 06/03/09 at 3:15 p.m., revealed Resident #13 enjoyed church, music, visits, and talking. She said she can see the care plan was not specific to Resident #13's interests. c) Resident #62 Review of Resident #62's care plan revealed a goal to attend and participate in exercise twice weekly, with interventions to include providing an activity calendar and encouraging her to go to activities. However, the care plan did not identify any specific activities Resident #62 enjoyed and could do. Review of her participation record for May 2009 found that, besides one-on-one visits and watching television, she took part in pre-meal activities in the dining room, exercise and rhythm band, and occasionally a trivia game or visits with family. Interview with the activity director, on 06/03/09 at 3:15 p.m., revealed Resident #62 enjoyed visiting and talking, and music, and she likes touch. She also reported Resident #62 got her nails done, which was not recorded in her participation record. She said she can see the care plan was not specific to Resident #62's interests. d) Resident #51 Review of Resident #51's care plan revealed a goal to attend and participate in activities two (2) or more times weekly, with an intervention to provide an activity calendar. However, the care plan did not identify any specific activities Resident #51 enjoyed or could do. Review of her participation record for May 2009 revealed she attended one (1) church service, exercised with the rhythm band, watched television, and received one-on-one visits in the room with activities personnel or family. Interview with the activity director, on 06/03/09 at 3:15 p.m., revealed Resident #51 especially liked to touch and hold hands or have her back rubbed, and she would often come into their department for that, as well as getting her nails done weekly. However, these activities were not recorded on her participation record, although she received them. The activity director reported Resident #51 enjoyed music at exercise class and church music. She agreed the care plan was not specific to Resident #51's interests. .",2014-09-01
11077,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,225,E,0,1,CKVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not assure all newly hired employees were screened through the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was evident for five (5) of ten (10) randomly selected facility staff. Employee identifiers: #46, #135, #79, #59, and #23. Facility census: 89. Findings include: a) Employees #46, #135, #79, #59, and #23 On 06/02/09, a random sample of five (5) recently hired employees and five (5) employees hired greater than twelve (12) months ago were reviewed to determine whether the facility had checked each employee through the WV nurse aide abuse registry prior to their date of hire at the facility. The personnel files of three (3) licensed practical nurses (LPNs - Employees #46, #135, and #79) and two (2) registered nurses (RNs - Employees #59 and #23) contained no evidence of the facility having checked them against registry for findings of abuse, neglect, mistreatment of [REDACTED]. Employee #35 concurred there was no such evidence in the personnel file for those five (5) employees and subsequently obtained registry checks for them on 06/02/09. .",2014-09-01
11078,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,309,D,0,1,CKVD11,"Based on observations of resident-staff interactions, staff interview, and review of medical records, the facility failed to ensure each resident was provided with the necessary care and services to attain or maintain his or her highest practicable level of well-being. A resident requested medication for a headache but did not receive the medication for more than twenty (20) minutes; the entire delay was not necessary. Additionally, this resident had recorded fluid output that far exceeded his fluid intake, and there was no evidence this had been recognized and assessed by staff. One (1) of fifteen current residents on the sample was affected. Resident identifier: #2. Facility census: 89. Findings include: a) Resident #2 1. On 06/02/09 at 12:56 p.m., while waiting to watch a nurse (Employee #53) do Resident #19's treatment, Resident #2 came to the nursing station and informed Employee #53 he needed something for a headache. The nurse, who was standing by the medication cart, told the resident she needed to go to the bathroom. While Resident #2 was waiting for the nurse's return, he was asked about his headache. He said he has a headache every day; if he does not have one (1) in the morning, he has one (1) in the evening. He said he had been hit in the back by a bottle rocket, and they did not know why he had the headaches. He added they gave him Extra Strength Tylenol for his headaches, and sometimes it worked and sometimes it did not. When she returned from the bathroom at 1:02 p.m., Employee #53 informed this surveyor she was going to get the things for Resident #19's treatment. She went down the hall and returned with the treatment cart. She then checked the treatment record a minute or two (2) later and said, ""Hold on a minute, (Resident #2's first name),"" and went inside the nursing station. She got a chart and talked to the registered nurse until 1:10 p.m.; the chart was not Resident #2's. At 1:12 p.m., the nurse returned to her medication cart and asked Resident #2 to rate his pain on a scale of 1-10. He said, ""7 to 8."" She looked in the drawer of the med cart and found there were no 325 mg Tylenol. She told the resident said would have to go look for some. The resident did not receive medication for his headache until 1:18 p.m.; this was eighteen (18) minutes after he had requested something for his headache. 2. Review of Resident #2's medical record found his fluid intakes and outputs had been recorded on forms entitled ""Comprehensive Intake-Output Record"". The twenty-four (24) hour intakes and outputs were found to be recorded in the nurses' notes. Review of the resident's current orders found monitoring of fluid intake and output had been ordered by the physician. The recordation of the 24-hour totals, for mid April 2009 through the end of May 2009, showed his fluid outputs were often more than twice what his intakes were on most days. For example: Date - 24-hr intake - 24-hr output 05/24/09 - 1080 cc - 1500 cc 05/25/09 - Not recorded in the nurses' notes 05/26/09 - 720 cc - 1300 cc 05/27/09 - 1740 cc - 2000 cc 05/28/09 - 840 cc - 1800 cc 05/29/09 - 1580 cc - 1840 cc 05/30/09 - 960 cc - 1800 cc 05/31/09 - 840 cc - 2000 cc Review of the resident's care plan, established 02/24/09 and continued on 05/26/09, found a problem of: ""Urinary elimination pattern, altered, related to presence of Indwelling Catheter; At risk for fluid volume deficit...."" The goal was for the resident to have at least 1000 cc of urinary output every 24-hours. The interventions included monitoring intakes and outputs and encouraging the consumption of 2000 cc of fluids daily. There was nothing found in the care plan, the nursing entries, or the fluid intake and output records to indicate the resident ingested fluids on his own. There was no evidence the resident had been asked to let staff know when he drank additional fluids or of any mechanism that might be implemented in an attempt to more accurately track the resident's fluid intakes. There was no evidence staff had recognized the resident's daily fluid outputs far exceeded his intakes. In an interview on 06/04/09 at approximately 1:30 p.m., the director of nursing was asked to review the resident's 24-hour totals. She said the night shift documented the 24-hour totals and it would be impossible to keep up with what resident drinks. .",2014-09-01
11079,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,323,E,0,1,CKVD11,"Based on observations and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. White metal covers were covered with rugs but protruded above the level of the surrounding floor, creating trip hazards. A nurse left a medication cart unlocked in the hall in the presence of mobile residents. A bottle containing corrosive disinfectant (Quat-256) was found in an unlocked storage room on the West wing. These deficient practices had the potential to affect all independently mobile residents. Facility census: 89. Findings include: a) During the survey, observations found trip hazards in the entry hall and the 800 hall of the West wing. White metal covers on the floors protruded above the level of the surrounding tile floor. These were covered with rugs. A survey team member reported she had tripped over the one in the hall near the entry of the facility. b) On 06/02/09 at 12:56 p.m., the nurse (Employee #53) left a medication cart unlocked when she went to the bathroom. Although the cart was in the hall outside of the nursing station, staff at the nursing station were occupied and not watching the cart (and had not been asked to watch). The surveyor was able to open any drawer on the cart. In an interview at approximately 1:30 p.m. on 06/04/09, the director of nursing was informed. She state the nurse knew better than to leave the med cart unlocked. c) During the initial tour of the West wing, storage areas were found to be locked with the exception of one (1). The storage area contained grooming supplies and other items. On a shelf, approximately three (3) feet off of the floor and directly across from the door to the room, was a spray bottle of disinfectant (Quat-256). The label on the bottle included, ""Danger Corrosive - Causes eye damage and severe skin irritation. Harmful if swallowed."" .",2014-09-01
11080,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,441,F,0,1,CKVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility's infection control program did not ensure staff employed practices to prevent the spread of infection. A nurse did not employ appropriate infection control techniques when changing Resident #19's dressing. A second nurse did not utilize good handwashing techniques during medication pass. A staff member contaminated the ice chest while passing ice water. These practices had the potential to affect all residents. Facility census: 89. Findings include: a) Resident #19 1. On 06/02/09 at 1:25 p.m., the nurse (Employee #53) was observed providing a treatment to Resident #19. She had contact with resident then, without removing her gloves, went to the treatment cart for scissors. She returned, cut off the old dressing, then put the scissors in her pocket. This created a potential for contamination of items in the treatment cart through transfer of organisms from the nurse's contaminated gloves. There was also a potential for transfer of organisms from the contaminated scissors to the nurse's pocket. 2. During this procedure, the nurse sprayed [MEDICATION NAME] onto some gauze 4 x 4s intended to cleanse the resident's wound. The spray bottle leaked, and the nurse used 4 x 4s to catch drips off of the bottle, then used the 4 x 4s on resident. This created a potential for microorganisms on the bottle to be transferred to the resident's wound. 3. Wearing contaminated gloves, the nurse retrieved a pen from her pocket, labeled the dressing, then put the pen back in her pocket. Again, this created a potential to transfer microorganisms from the resident's wound to the pen and her pocket and a potential for subsequent transfer of those microorganisms to others. b) Resident #84 On 06/02/09 at 8:23 a.m., during medication administration pass, a second nurse (Employee #34) was observed washing her hands. The nurse turned the water off with paper towels, then used the paper towels to dry her hands. This created a potential for recontamination of the nurse's hands with the organisms for which she had just washed her hands and any others residing on the faucet controls. c) Observation of ice pass, during the morning of 06/03/09, revealed the staff member providing ice retrieved the water pitchers from residents' rooms, filled the pitchers while holding them over the chest containing clean ice (allowing the scoop to come into contact with the pitchers), then dropped the scoop into the ice. .",2014-09-01
11081,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,514,D,0,1,CKVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure one (1) of fifteen (15) current residents on the sample had a determination of capacity form which contained conflicting information. The documentation indicated the resident had ""capacity"", and yet his ""incapacity"" was expected to be short term. Resident identifier: #2. Facility census: 89. Findings include: a) Resident #2 The ""Physician Determination of Capacity"" form, completed by the physician on 11/14/07, contained conflicting information. The physician had checked: ""(The resident) demonstrates CAPACITY to make medical decisions."" Below that, the form included, ""Expected duration of incapacity: ____ short term ____long term."" The physician had checked ""short term"". Under that was a prompt that read: ""The decisions is based on the following: Cause (Diagnosis):""; ""[MEDICAL CONDITION]"" had been written as the cause of incapacity. It was unclear, due to this conflicting documentation, whether or not the resident possessed the capacity to make informed medical decisions.",2014-09-01
11082,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,465,F,0,1,CKVD11,"Based on observations, the facility did not provide a comfortable environment for the residents, staff, and the public. The handrails throughout the building were in need of refinishing. Tile floors had gaps that could harbor bacteria. Wall repairs and painting had not been done neatly. The fan in the West wing women's bathing area was laden with dust and hair-like substances. The dining areas were dark and drab. And the overall appearance of the buildings interior was gloomy. All residents, staff, and the public had the potential to be affected. Facility census: 89. Findings include: a) During the initial tour of the facility, observation revealed the handrails throughout the building needed to be refinished. As one felt the surface, it was noted to be somewhat rough in many areas. In one area, there was a bit of thread stuck in the railing, as though it had been caught in the rough finish when cleaned. The handrails had a somewhat dark finish, but numerous areas were lighter, as though the stain had been removed. b) In many areas, the cove base, especially around the heating / ventilation units, had gaps in it and was in need of repair. c) Numerous areas around doors, floors, etc., had been caulked and painted. This had not been done neatly and was unattractive. d) There were areas on the floors that were uneven due to metal plates having been affixed to the floor resulting in uneven areas. e) A fan in the West wing women's central bath was heavily laden with dust and stringy, hair-like substances. f) Surfaces in the public bathrooms were dusty, especially near the doors to the rooms. g) The main dining room had dark table cloths, cabinets that were aged, and the overall presentation was not visually appealing. h) The doors to the residents' rooms had multiple areas where it was apparent things had been taped to the doors and the finish removed and/or residue from the tape remained. This was not visually appealing. i) In an interview with the administrator on the morning of 06/02/09, he acknowledged the facility was in need of renovation. He agreed improvements were needed to make the building's interior more attractive to residents and their families. .",2014-09-01
11083,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,174,E,0,1,CKVD11,"Based on observation and staff interview, the facility failed to provide a private location for a resident's phone call; this was true for one (1) of fifteen (15) sampled residents. A resident was observed utilizing the telephone at the facility's nursing station to have a conversation with a family member. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. This practice has the potential to affect more than an isolated number of residents, including those who wish to make and receive calls and do not have private telephones in their rooms. Resident identifier: #51. Facility census: 89. Findings include: a) Resident #51 On 06/04/09 at 11:30 a.m., Resident #51 was wheeled down to the west wing nursing station and handed the telephone receiver. Several staff members were observed standing near the resident. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. Staff interview with a licensed practical nurse (LPN - Employee #1), on 06/04/09 at 11:35 a.m., revealed the resident was not offered a private location for the phone call. The LPN further stated the west wing nurses' station does not have a cordless phone for the residents to use. The LPN stated the residents use the activity office to make personal calls at times, yet this option was not offered to Resident #51 for this phone call. .",2014-09-01
11084,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,248,D,0,1,CKVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide an individualized activity program for one (1) of fifteen (15) sampled residents. A [AGE] year old, blind resident was not offered an activity program to meet his needs and interests. Resident identifier: #68. Facility census: 89. Findings include: a) Resident #68 Resident #68, when interviewed on 06/02/09 at 1:30 p.m. and on 06/03/09 at 3:00 p.m., reported he had a stroke approximately six (6) years ago resulting in [MEDICAL CONDITION]. The resident was divorced and rarely received any visitors. He had a fall resulting in a [MEDICAL CONDITION] in April 2009 and was admitted to the facility for rehabilitative therapy services. The resident reported his life work was sports, having been a sports writer for a newspaper and a golf coach, and his primary interest was in sports, but the facility did not provide any activities relating to his interest in sports. The resident stated he would like to listen to, or attend any sporting events, yet the facility did not offer any of these activities. The resident stated he had a television in his room but did not have access to the national sport channels, yet other residents in the facility did. (The facility administrator was notified of this by the surveyor, and his TV was reprogrammed on 06/02/09, allowing the resident access to sports channels.) He related facility staff did not offer to read any sports magazines to him. The resident also stated he would like to go for walks outside with staff, but this activity was also not offered to him. The activity director (Employee #64), when interviewed on 06/03/09 at 4:30 p.m., reported Resident #68's planned activities included listing to radio and TV, exercise, music, and coming into the activity office daily to drink coffee and have the obituaries read to him. Review of Resident #68's medical record, on 06/04/09 at 10:00 a.m., found the resident's current plan of care did not address specific activity / social needs, likes, and/or interest for this [AGE] year old blind resident. The resident's activity assessment, dated 05/12/09, identified the resident had been a golf coach and sports writer; however, the activity progress notes, dated 05/12/09 and 05/20/09, failed to address the residents' strong interest in sports. The activity participation record for May 2009, when reviewed, found the resident had not participated in sport-related activities. .",2014-09-01
11085,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,371,F,0,1,CKVD11,"Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 89. Findings include: a) During the initial tour of the dietary department at 2:00 p.m. on 06/01/09, plate covers, plastic cups, and steam table pans were noted to be stacked inside each other or inverted on trays prior to complete air drying. These items were observed with trapped moisture, creating a medium for bacterial growth. b) Flies were observed in the serving and food preparation area of the kitchen during the initial tour on 06/01/09. .",2014-09-01
11086,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,364,F,0,1,CKVD11,"Based on the group interview, staff interview, and taste testing, the facility failed to assure foods were seasoned with salt as directed by the recipe. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 89. Findings include: a) During the confidential group interview at 1:30 p.m. on 06/02/09, residents expressed dissatisfaction with the flavor of the foods they received. Further inquiry revealed they felt the foods were not well seasoned. b) On 06/03/09, during the noon meal, mashed potatoes were taste tested . This testing was done with the dietary manager (DM). The mashed potatoes did not appear to have been seasoned. The DM tasted the mashed potatoes and confirmed they needed additional salt. Interview with the cook who prepared the potatoes revealed the directions on the container had not been followed relative to the amount of salt which should have been added to the mashed potatoes. .",2014-09-01
11087,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-05-25,225,D,1,0,3XM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's abuse investigation files, medical record review, and staff interview, the facility failed to provide protection to one (1) of twenty-nine (29) Stage II sample residents, during an investigation into an allegation of sexual assault made by a female resident (#79) against a male resident (#72). Resident #72 was allowed to remain on the same unit, in a room across from Resident #79's room, from the time of the incident on 02/28/11 at 05:15 p.m. through 03/02/11 at approximately 3:30 p.m., when the Resident #72 was transferred to an emergency department for medical clearance (after which he was admitted to an inpatient psychiatric unit). Facility census: 94. Findings include: a) Resident #79 Review of the facility's records of self-reported allegations of abuse / neglect found an immediate report, dated 02/28/11, stating that at 5:00 p.m. on that date, ""Female resident reported she was raped by male resident."" The female resident was identified as Resident #79, and the male resident was identified as Resident #72. Per this report, immediate actions taken by the facility included placing an alarm on Resident #72's door and sending Resident #79 to the hospital for examination. The five-day follow-up report to this incident, dated 03/04/11, stated the results of the examination of Resident #79 were not yet available, Resident #72 was placed on 15-minute checks, an alarm was placed on the door to his room, and he was sent out for an evaluation of his medication regimen and was currently out of the facility. The report also stated: ""Female resident will be moved to another unit. "" Both the immediate and five-day follow-up reports were signed as having been completed by one (1) of the facility's social workers (Employee #187). -- Review of the incident / accident report associated with the above event involving Resident #79, which was prepared by a licensed practical nurse (LPN - Employee #158) on 02/28/11, found the following description of the event: ""HSW (health service worker) heard cries coming from room (#). Res. (resident) laying supine on bed, dress was pushed up and brief to side, genitals exposed. (Resident #72) was standing by bed, near genitals. (Resident #72) had pants on but penis exposed. "" In the section where staff was to record the resident's response was written: ""HSW asked res. 'Did he hurt you?' Res replied 'He tried to f*** me.' Res was escorted to DR (dining room) for supper."" -- Review of witness statements obtained by the facility revealed the following from the HSW who found the residents (Employee #112) dated 03/01/11 (quoted as written): ""I went to the unit from the dining room to check and see if everyone was still on the unit and needed to be taken to dining room for supper. I heard resident (#79) crying from her room. I went in to see what was going on. She was on the bed with her dress pulled up to her waist and her brief was pulled to the side and her genitals were exposed. I ask her if she was hurt she stated he tried to f--- me. ""Resident (#72) was standing at the bottom of her bed with his penis out of his pants. His pants was up. His penis was erect. ""I took resident (#79) to the dining room with me. Resident (#72) followed us to the dining room. Then he got on elevator and went to G-3 for supper. ""After supper went to lab and got stop sign with alarm and put it on resident (#72) door. Check every 15 min until 8P when resident (#79) went to PMH (local hospital). ""Incident was on 2-28-11."" -- Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Cognitively, she scored ""5"" on the brief interview for mental status (BIMS). (According to CMS's RAI Version 3.0 Manual, a score in the range of ""0 - 7"" indicates severe cognitive impairment.) A progress note recorded in Resident #72's electronic medical record, signed by an LPN at 22:20 (10:20 p.m.) on 02/28/11 (quoted as typed), stated: ""At 5:15p, HSW reported to this nurse that (Resident #72) had been in (Resident #79's) room and was observed displaying inappropriate sexual behavior. (Resident #72) removed from room and (Resident #79) was assisted to DR for supper. Social worker notified by this nurse. Dr. (name) notified and orders received to send res. to PMH at 9p via ambulance, other appropriate parties notified. ..."" An entry, signed by the director of nursing (DON) at 11:45 (11:45 a.m.) on 03/01/11, stated: ""LPN that picked up resident from the ER last evening stated that she picked up resident at approx 11:30 pm and returned to Hopemont at 12 midnight. ... LPN also reported to this DON that 2 police officers came to Hopemont last night to investigate this incident."" An entry, signed by an LPN at 03:56 (3:56 a.m.) on 03/01/11, stated: ""Resting in bed with eyes closed. No c/o (no complaints) voiced. Will continue to monitor."" An entry, signed by a social worker at 12:05 (12:05 p.m.) on 03/03/11, stated: ""Psychology staff have recommended that (Name of Resident #79) would benefit from having a roommate. I also recommend that she be moved to a different unit due to the incident involving a male resident on her unit. ..."" An entry, signed by a member of the psychology staff at 14:45 (2:45 p.m.) on 03/03/11, stated: ""I stopped by (Resident #79's) room this afternoon. She was awake, but in bed, and requested that I take her to the store. We did so, then wrote a letter to her sister and left it on her social worker's desk. (Resident #79) asked me to talk to her. We visited as we walked upstairs. (Resident #79) was pleasant, but had very flat affect throughout the conversation. When asked if she would like to have a roommate, (Resident #79) replied that she would. Once back in her room, (Resident #70) decided to take a nap, and this writer left the room."" -- Review of Resident #72's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to his admission MDS with an ARD of 03/01/11, he was either independent or required only supervision / oversight with the self-performance of all activities of daily living, including transferring and ambulation. Cognitively, he was unable to complete the BIMS. A progress note recorded in Resident #72's electronic medical record, signed by an LPN at 10:53 (10:53 a.m.) on 03/01/11 (quoted as typed), stated: ""At 0900 removed his stop sign to his door and Hsw replaced it and redirected resident.At 0915 resident took stop sign down and HSW replaced it and told staff he took it down and walked down the hall.At 1015 HSW put up sign.Resident was in bed and sat up and poiting finger and telling HSW to take down over,over he said he was a cop and would arrest her.Resident redirected resident and he laid down and sign was put up.At 1025 resident came out of his room, took sign down and walked up hall and told HSW he was a cop and had abadge and he could do whatever he wanted."" An entry, signed by the DON at 11:53 (11:53 a.m.) on 03/01/11, stated: ""Resident has been placed on 15 minutes checks. ..."" An entry, signed by an LPN at 12:44 (12:44 p.m.) on 03/01/11, stated (quoted as typed): ""Resident remains on Q (every) 15 min checks d/t (due to) inappropriate sexual behavior.At 1130 resident pointing finger at other residents in w/c (wheelchair) stating he was a cop. and he was putting them in Weston because they were in a w/c."" On 03/02/11 around 3:30 p.m., Resident #72 left the facility with two (2) members of the facility's nursing staff for the local emergency department, to be medically cleared before being admitted to another hospital's inpatient psychiatric unit, according to the nursing notes. -- An interview with the administrator, on 05/24/11 at 9:30 a.m., confirmed neither resident was moved from the unit for two (2) days following the incident. The administrator agreed Resident #72 should have been moved off of Resident #79's unit until he could be sent out to the emergency department. -- Review of the facility's policy titled ""Resident Advocacy Services"" (dated 07/01/00) found, under the heading ""Discussion"", Item #13 stated: ""The Resident Advocate shall advocate for ALL RESIDENTS and ensure ALL Rights are maintained, ensure, and protected."" -- In an interview with two (2) social workers (Employees #186 and #187) on 05/25/11 at 10:00 a.m., Employee #186 said she thought there may have been nowhere to move Resident #72. As of exit on 05/25/11 at 1:00 p.m., no additional information was available regarding this matter. -- This surveyor was unable to verify, through record review or staff interview, that Resident #79 experienced any distress related to having Resident #72 remain on the same unit in a room across from hers until he was transferred out of the facility on the afternoon of 03/03/11. .",2014-09-01
11088,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-05-25,309,G,1,0,3XM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to adequately assess one (1) of twenty-nine (29) Stage II sample residents for injuries immediately following a fall. Resident #63, who was totally dependent on staff for the performance of all activities of daily living (ADLs), fell from a reclined chair onto the floor and was not adequately assessed for injuries after the fall. The resident remained in the facility for two (2) days without physician intervention, receiving only Tylenol for pain. She was later assessed as having outward rotation of her right lower extremity and was subsequently transferred to the hospital, where she was diagnosed with [REDACTED]. Facility census: 94. Findings include: a) Resident #63 1. Record review revealed this [AGE] year old female was readmitted to the facility on [DATE], following a stay in the hospital for a [MEDICAL CONDITION]. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 05/19/11, identified the following problem: "" Potential for falls due to unsteady gait, recent right [MEDICAL CONDITION] (slid out of recliner), history of a left [MEDICAL CONDITION]. "" The goal associated with this problem statement was: "" No further injuries. "" Interventions to achieve this goal included providing the resident with a recliner with a pad alarm to alert staff of needed assistance, chair and bed pad alarms to alert staff for assistance, mat at bedside, and Hipsters on at all times. In the previous MDS, a quarterly assessment with an ARD of 04/21/11, the assessor noted the resident was dependent on staff for all ADLs, and that she did not walk, had functional limitation to her lower extremities, and she utilized a wheelchair for locomotion. -- 2. Review of the resident ' s electronic medical record found the following progress note entries: - On 04/29/11 at 21:38 (9:38 p.m.), a licensed practical nurse (LPN - Employee #152) recorded (quoted as typed): ""HSW (health service worker) heard (name of Resident #63) yelling and found her on floor in front of her recliner. Recliner had a sheet and pad and (name of Resident #63) slide onto the floor directly in front of chair. No injuries seen, no first aid needed. Charge nurse ADON (assistant director of nursing), Social worker notified."" - On 04/30/11 at 05:59 (5:59 a.m.), a registered nurse (RN - Employee #81) recorded (quoted as typed): ""Resting comfortably tonight. No s/s (signs / symptoms) or c/o (complaints of) pain or discomfort noted. No apparent injury from sliding out of recliner."" - On 04/30/11 at 09:08 (9:13 a.m.), an LPN (Employee #125) recorded (quoted as typed): ""Resident c/o (complained of ) right leg pain. Received Tylenol tabs 2 at 7:45am. Resident placed in bed, with no noted bruising or malformation noted at this time. Will cont (continue) to monitor. "" - On 04/30/11 at 14:16 (2:16 p.m.), Employee #125 recorded (quoted as typed): "" Resident up for lunch. Ate poor. Charge nurse checked resident at this time. Spoke with Dr. (name) ... wants resident observed for increase in pain, bruising. Will observe. "" - On 04/30/11 at 14:27 (2:27 p.m.), an RN (Employee #145) recorded (quoted as typed): ""Assessed res. (resident) while in bed; awake; positioned supine approx. 3cm dark purple flat area on right dorsal upper forearm; PROM (passive range of motion) of upper ext. (extremity) without complaint or evidence of discomfort; res. leans lower extremeties toward right when supine. sustains left foot briefly when supine then food moved medially toward right; right foot sustained briefly then moves laterall (however, not fully) toward right; res did not grimace on exam but moved my hand when right leg was examined. There is not redness, bruising or swelling of hips or legs1. Dr. (name) was notified. Monitoring. "" - On 05/01/11 at 06:26 (6:26 a.m.), an LPN (Employee #72) recorded (quoted as typed): ""Resident yelling during care this am care. Tylenol supp (suppository) 65 mg rectally given. Some eversion (meaning "" turning outward "" ) noted to RLL (right lower leg), 7-3 nurse aware and planning to notify Dr. (name). "" - The next consecutive entry, recorded by Employee #125 on 05/01/11 at 08:12 (8:12 a.m.), was labeled a Resident Transfer Form. Under the heading "" Reason for Transfer "" , the nurse recorded (quoted as typed): "" Fall on 4/29/11. No noted injury at the time. At present, resident screaming in pain on movement. Difficult to access d/t (due to) mental status. Resident will read notes written, stated her right leg hurts bad. "" Resident #63 was subsequently picked up by the ambulance service at 9:15 a.m. and transferred to Hospital #1 ' s emergency room for evaluation. She was later transferred to Hospital #2. - On 05/01/11 at 19:27 (7:27 p.m.), Employee #152 recorded having received a call from staff at Hospital #2 stating they wanted to perform surgery on her hip. -- 3. An interview with Employee #72, on 05/23/11 at 1:15 p.m., revealed the resident was not adequately assessed for injuries after she fell on [DATE]. The RN did not check for any rotation to the legs. She further stated, ""When I assessed the resident two (2) days later on 05/01/11, the resident had an eversion to the right leg. "" -- 4. In an interview on 05/25/11 at 10:15 a.m., the director of nursing (DON) stated she felt the nurse should have documented a complete assessment of the resident on the day the resident fell . She further stated, ""To only write that the resident was not injured and required no interventions was not suitable. The nurse should have documented all areas, if he assessed the resident appropriately."" -- The facility failed to assess the resident for any abnormalities of her lower extremities immediately after she fell from the reclined chair. Two (2) days after the fall, an RN assessed the resident and found an eversion to the resident's right leg. The physician was notified, and the resident was transferred to the hospital and diagnosed with [REDACTED]. .",2014-09-01
11089,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-05-25,431,E,1,0,3XM311,". Based on observation, staff interview, medical record review, and review of facility training records and policy and procedures for medication administration, the facility failed to prepare, store, secure, and dispose of medications as required. For two (2) of four (4) medication rooms observed, the facility failed to follow its own policy to discard opened multi-dose vials of insulin after twenty-eight (28) days. This occurred for insulins for Residents #41 and #18. A medication cart on Unit A2 was left unlocked and out of the line of sight of the nurse assigned to the cart, with controlled substances in an open unlocked drawer, accessible to passersby. A medication cart on Unit B12 was left unattended with bubble packages of Tramadol, Lorazepam, Methylin, and Tramadol on the top of the cart at the nurses' station. A medication cart located on Unit A1 was found in the medication room by the assistant director of nursing (ADON - Employee #131). On top of the cart was a medication cup containing an unlabeled pre-poured mixture of crushed medications in pudding. Facility census: 94. Findings include: a) Unit A2 medication cart 1. On 05/16/11 at 8:45 a.m., a registered nurse (RN - Employee #165) was observed in a resident's room away from the medication cart which was left unlocked, unattended, and out of the nurse's line of sight. Two (2) drawers were observed open on the cart. One (1) of the drawers contained controlled substances that were supposed to be stored in a locked compartment within the medication cart. These included Hydrocodone, Oxycodone, Lorazepam, Clonazepam, Tylenol #3, Phenobarbital, and Depakote. An unidentified resident was observed wandering by the medication cart during this observation. The administrator was present during this observation. 2. On 05/15/11 at 10:15 a.m., the director of nursing (DON), when interviewed, agreed that the nurse should not have left the cart unattended and unlocked with medications left out of the lock box. She provided the facility's Drug Administration policy and procedure (dated 04/06/11). Item 4.G. of the policy / procedure stated: ""NEVER LEAVE: ""1. Medication on top the cart. ""2. Cart unattended without being locked. ""3. Cart / storage key with unauthorized personnel ""4. Medication room unlocked."" She also provided two (2) knowledge / skills check-off forms completed by Employee #165 on 08/12/10. One form was titled ""Medication Administration Observation / Drug Storage, Drug Storage and Labeling"" and asked: ""Were drugs and biological in medication rooms, carts, boxes, and refrigerators maintained within: - Secured (locked location, accessible only t to designated staff - Clean and sanitary conditions - Temperatures under 86 (degrees) F for room storage, and 36-46 (degrees) for refrigerated. medications. - A separate key (in possession of staff) for schedule II controlled drugs and drugs subject to abuse, which is accessible only to authorized personnel."" The other form, titled ""Medication Pass"", reflected that Employee #165 was checked off by the ADON on 08/12/10 for ""Medication Pass"" and included ""Keep cart in sight or locked at all times."" -- b) Unit B2 medication cart 1. On 05/16/11 at 9:10 a.m. on Unit B2, bubble packages of Tramadol, Lorazepam, Methylin, and Tramadol were observed on the top of the medication cart at the nurses' station. The ADON was present during this observation. When the RN who was attending the cart (Employee #101) was questioned about why the medications were on top of the cart, she responded that she was finished with the medication pass but had ""not signed them out"". She said she left the medications on the top of the medication cart as she was doing the medication pass, so she could remember to sign the narcotics book, indicating she gave the medications. She picked up the narcotics book that was at the nurse's station and said she had not taken the book with her when she passed the medications. A comparison of the narcotics book and medications at this time with the ADON confirmed Employee #101 had not signed out the medications. At 10:30 a.m., Employee #101 was interviewed again. She stated she was a 90-day temporary employee and did not remember being inserviced regarding medication administration. 2. On 05/16/11 at 10:15 a.m., the DON provided two (2) forms she used to inservice staff. The first form was Form CMA- (dated 10/07 and titled ""Medication Administration Observation / Drug Storage""). The second form was titled ""Medication Pass"" (dated 04/14/03 and revised 02/11/09). She said nurses were inserviced with these forms for Medication Passes. On the Medication Pass form, in the Documentation section, was found the following: ""Controlled meds signed out as administered."" -- c) Unit A1 medication cart 1. On 05/15/11 at 09:10 a.m., observation of the medication cart for Unit A1, with the ADON, found it was located in the medication room. On top of the cart was a medication cup containing a mixture of pre-poured crushed medications in pudding. The medication cup was missing when the ADON brought the cart out to the nurse's station. The licensed practical nurse (LPN - Employee #92) who was assigned to the medication cart, when interviewed, stated she had given medications to all but one (1) resident, and she left the medications on the top of the medication cart. The ADON went back into the med room and brought out the medication cup containing the crushed meds in pudding, telling Employee #92 she took it off the med cart because she was not sure whose medication it was. Employee #92 said the other nurse (Employee #125), who was also at the nurse's station, saw her put the crushed medications together for Resident #31 and would be giving the medications to the resident, as Employee #92 had to leave for an emergency. Employee #125 (also an LPN) verified that she saw Employee #92 put the medications together. 2. Review of the facility's Drug Administration policy and procedure (dated 04/06/11) found Item #5. B. stated, ""Medications shall be prepared and administered b the same individual and shall never be pre-poured. During a review of the policy with the DON on 05/16/11 at 10:15 p.m., she stated the policy was specific and medications were never to be prepared by one (1) nurse and given by another. d) Resident #41 Observation of the medication room refrigerator on Unit B1, on 05/25/11 at 9:45 a.m., revealed a vial of Humulin-R insulin prescribed for Resident #41. This vial was marked as having been opened on 04/23/11 and with a discard date of 05/20/11. During an interview with the nurse (Employee #166) on 05/25/11 at approximately 9:45 a.m., she stated she believed insulin vials are supposed to be discarded after twenty-eight (28) days. At this time, another nurse (Employee #139) referred to a ""Recommended Minimum Medication Storage Parameters"" sheet taped to the outside door of a cabinet in the medication room. Review of this posting for storage requirements of insulin products (all vials) found the following statement: ""Based on American Diabetes Association guidelines, all unopened insulins are recommended to be stored in the refrigerator. All product should be discarded 28 days after opening."" Record review of the Medication Administration Record [REDACTED]. -- e) Resident #18 Observation of the medication room refrigerator on Unit A2, on 05/25/11 at 10:00 a.m., revealed a vial of Novolin-R insulin prescribed for Resident #18. This vial was marked as having been opened on 04/18/11. During an interview with the nurse (Employee #123) on 05/25/11 at approximately 10:00 a.m., she stated that insulin vials are supposed to be discarded after twenty-eight (28) days. The discard date for this vial of insulin should have been 05/16/11. She then ordered a new vial of insulin for Resident #18. Record review of the MAR for Resident #18 found he received 2 units of Novolin-R insulin coverage on 05/21/11 at 5:26 a.m. for blood sugar of 246. During an interview Employee #139 on 05/25/11 at 12:45 p.m., she stated she was unable to find a facility policy related to discard dates of opened vials of insulin other than the ""Recommended Minimum Medication Storage Parameters"" sheets that are taped to the cabinets in each unit's medication room. .",2014-09-01
11090,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-05-25,441,F,1,0,3XM311,". Based on a review of the facility's tracking system for determining resident infections and staff interview, the facility did not track the pathogens causing twenty-seven (27) of twenty-seven (27) infections for a three (3) month period. By not identifying the infectious organisms, the facility would not be able to conduct tracking / trending of infections to map their spread. This practice had the potential to affect all residents in the facility. Facility census: 94. Findings include: a) A review of the facility's ""Monthly Infections / Antibiotic"" log for the months of February, March, and April 2011 found listed the names of each resident identified as having an infection, the antibiotics ordered, the types of infection, the follow-up actions to prevent spread of infection, the dates, and the nurse's signature. The log did not, however, identify the pathogen causing each infection. An interview with the assistant director of nursing / infection control nurse (Employee #131), on 05/23/11 at 11:00 a.m., confirmed pathogens were not listed on the infection control log. She further stated, ""I was given this job recently and was not aware that I needed to record the pathogen. I thought I only needed to record the actual infection. It makes sense that I would need to know the pathogen to determine if a trend exists on the hallways for the QA."" The types of infections recorded for the three (3) month period included urinary tract infection, upper respiratory infection, cellulitis, sepsis, pneumonia, and bronchitis. An interview with the director of nursing, on 05/24/11 at 2:00 p.m., revealed the facility did not have a policy and procedure for tracking infections. .",2014-09-01
11091,HOPEMONT HOSPITAL,5.1e+149,"ROUTE 3, BOX 330",TERRA ALTA,WV,26764,2011-05-25,226,E,1,0,3XM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's abuse investigation files, medical record review, and staff interview, the facility failed operationalize policies and procedures to ensure the protection of one (1) of twenty-nine (29) Stage II sample residents, during an investigation into an allegation of sexual assault made by a female resident (#79) against a male resident (#72). Resident #72 was allowed to remain on the same unit, in a room across from Resident #79's room, from the time of the incident on 02/28/11 at 05:15 p.m. through 03/02/11 at approximately 3:30 p.m., when the Resident #72 was transferred to an emergency department for medical clearance (after which he was admitted to an inpatient psychiatric unit). Facility census: 94. Findings include: a) Resident #79 Review of the facility's records of self-reported allegations of abuse / neglect found an immediate report, dated 02/28/11, stating that at 5:00 p.m. on that date, ""Female resident reported she was raped by male resident."" The female resident was identified as Resident #79, and the male resident was identified as Resident #72. Per this report, immediate actions taken by the facility included placing an alarm on Resident #72's door and sending Resident #79 to the hospital for examination. The five-day follow-up report to this incident, dated 03/04/11, stated the results of the examination of Resident #79 were not yet available, Resident #72 was placed on 15-minute checks, an alarm was placed on the door to his room, and he was sent out for an evaluation of his medication regimen and was currently out of the facility. The report also stated: ""Female resident will be moved to another unit. "" Both the immediate and five-day follow-up reports were signed as having been completed by one (1) of the facility's social workers (Employee #187). -- Review of the incident / accident report associated with the above event involving Resident #79, which was prepared by a licensed practical nurse (LPN - Employee #158) on 02/28/11, found the following description of the event: ""HSW (health service worker) heard cries coming from room (#). Res. (resident) laying supine on bed, dress was pushed up and brief to side, genitals exposed. (Resident #72) was standing by bed, near genitals. (Resident #72) had pants on but penis exposed. "" In the section where staff was to record the resident's response was written: ""HSW asked res. 'Did he hurt you?' Res replied 'He tried to f*** me.' Res was escorted to DR (dining room) for supper."" -- Review of witness statements obtained by the facility revealed the following from the HSW who found the residents (Employee #112) dated 03/01/11 (quoted as written): ""I went to the unit from the dining room to check and see if everyone was still on the unit and needed to be taken to dining room for supper. I heard resident (#79) crying from her room. I went in to see what was going on. She was on the bed with her dress pulled up to her waist and her brief was pulled to the side and her genitals were exposed. I ask her if she was hurt she stated he tried to f--- me. ""Resident (#72) was standing at the bottom of her bed with his penis out of his pants. His pants was up. His penis was erect. ""I took resident (#79) to the dining room with me. Resident (#72) followed us to the dining room. Then he got on elevator and went to G-3 for supper. ""After supper went to lab and got stop sign with alarm and put it on resident (#72) door. Check every 15 min until 8P when resident (#79) went to PMH (local hospital). ""Incident was on 2-28-11."" -- Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Cognitively, she scored ""5"" on the brief interview for mental status (BIMS). (According to CMS's RAI Version 3.0 Manual, a score in the range of ""0 - 7"" indicates severe cognitive impairment.) A progress note recorded in Resident #72's electronic medical record, signed by an LPN at 22:20 (10:20 p.m.) on 02/28/11 (quoted as typed), stated: ""At 5:15p, HSW reported to this nurse that (Resident #72) had been in (Resident #79's) room and was observed displaying inappropriate sexual behavior. (Resident #72) removed from room and (Resident #79) was assisted to DR for supper. Social worker notified by this nurse. Dr. (name) notified and orders received to send res. to PMH at 9p via ambulance, other appropriate parties notified. ..."" An entry, signed by the director of nursing (DON) at 11:45 (11:45 a.m.) on 03/01/11, stated: ""LPN that picked up resident from the ER last evening stated that she picked up resident at approx 11:30 pm and returned to Hopemont at 12 midnight. ... LPN also reported to this DON that 2 police officers came to Hopemont last night to investigate this incident."" An entry, signed by an LPN at 03:56 (3:56 a.m.) on 03/01/11, stated: ""Resting in bed with eyes closed. No c/o (no complaints) voiced. Will continue to monitor."" An entry, signed by a social worker at 12:05 (12:05 p.m.) on 03/03/11, stated: ""Psychology staff have recommended that (Name of Resident #79) would benefit from having a roommate. I also recommend that she be moved to a different unit due to the incident involving a male resident on her unit. ..."" An entry, signed by a member of the psychology staff at 14:45 (2:45 p.m.) on 03/03/11, stated: ""I stopped by (Resident #79's) room this afternoon. She was awake, but in bed, and requested that I take her to the store. We did so, then wrote a letter to her sister and left it on her social worker's desk. (Resident #79) asked me to talk to her. We visited as we walked upstairs. (Resident #79) was pleasant, but had very flat affect throughout the conversation. When asked if she would like to have a roommate, (Resident #79) replied that she would. Once back in her room, (Resident #70) decided to take a nap, and this writer left the room."" -- Review of Resident #72's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to his admission MDS with an ARD of 03/01/11, he was either independent or required only supervision / oversight with the self-performance of all activities of daily living, including transferring and ambulation. Cognitively, he was unable to complete the BIMS. A progress note recorded in Resident #72's electronic medical record, signed by an LPN at 10:53 (10:53 a.m.) on 03/01/11 (quoted as typed), stated: ""At 0900 removed his stop sign to his door and Hsw replaced it and redirected resident.At 0915 resident took stop sign down and HSW replaced it and told staff he took it down and walked down the hall.At 1015 HSW put up sign.Resident was in bed and sat up and poiting finger and telling HSW to take down over,over he said he was a cop and would arrest her.Resident redirected resident and he laid down and sign was put up.At 1025 resident came out of his room, took sign down and walked up hall and told HSW he was a cop and had abadge and he could do whatever he wanted."" An entry, signed by the DON at 11:53 (11:53 a.m.) on 03/01/11, stated: ""Resident has been placed on 15 minutes checks. ..."" An entry, signed by an LPN at 12:44 (12:44 p.m.) on 03/01/11, stated (quoted as typed): ""Resident remains on Q (every) 15 min checks d/t (due to) inappropriate sexual behavior.At 1130 resident pointing finger at other residents in w/c (wheelchair) stating he was a cop. and he was putting them in Weston because they were in a w/c."" On 03/02/11 around 3:30 p.m., Resident #72 left the facility with two (2) members of the facility's nursing staff for the local emergency department, to be medically cleared before being admitted to another hospital's inpatient psychiatric unit, according to the nursing notes. -- An interview with the administrator, on 05/24/11 at 9:30 a.m., confirmed neither resident was moved from the unit for two (2) days following the incident. The administrator agreed Resident #72 should have been moved off of Resident #79's unit until he could be sent out to the emergency department. -- Review of the facility's policy titled ""Resident Advocacy Services"" (dated 07/01/00) found, under the heading ""Discussion"", Item #13 stated: ""The Resident Advocate shall advocate for ALL RESIDENTS and ensure ALL Rights are maintained, ensure, and protected."" -- In an interview with two (2) social workers (Employees #186 and #187) on 05/25/11 at 10:00 a.m., Employee #186 said she thought there may have been nowhere to move Resident #72. As of exit on 05/25/11 at 1:00 p.m., no additional information was available regarding this matter. -- This surveyor was unable to verify, through record review or staff interview, that Resident #79 experienced any distress related to having Resident #72 remain on the same unit in a room across from hers until he was transferred out of the facility on the afternoon of 03/03/11. .",2014-09-01
10963,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,225,D,1,0,E59N11,". Based on record review and staff interview, the facility failed to adequately investigate an incident where a resident experienced significantly poor foot hygiene while allegedly receiving daily bed baths and failed to follow its own plan of correction to prevent recurrence of this deficient practice to the resident or to others. This practice affected one (1) of twenty-one (21) sampled residents. Resident identifier: #43. Facility census: 108. Findings include: a) Resident #43 Record review of an immediate fax report of allegations to the Nursing Home Program on 05/09/11 revealed facility staff reported an incident which occurred on 05/08/11, related to Resident #43 found wearing stained and malodorous socks. Review of interdisciplinary progress notes and witness statements revealed his feet and socks had a foul odor, the stench of which permeated the hallway outside the resident's room; the socks the resident was wearing were hardened, stuck to his feet, and difficult to remove. Further witness statements stated he had filth between his toes, and his feet were very white and wrinkled, having the appearance of having soaked in water a long time; Employee #19 (nursing assistant) stated this resident cannot bend over and take off his socks; Employee #97 (nursing assistant) stated he sleeps in his clothes; and Employee #38 (nursing assistant) stated he has never seen the resident in a gown. Review of the May 2011 shower record revealed he refused a shower on 05/07/11 and was already dressed; bed baths were documented as having been given on 05/03/11, 05/04/11, 05/05/11, and 05/06/11, and a partial bath was documented as having been given on 05/07/11. Review of the five-day follow-up report to the Nursing Home Program on 05/13/11 revealed the outcome of the facility's internal investigation found Resident #43 had soiled socks on 05/08/11, and had refused a shower on 05/07/11, noting he chooses to complete his own morning care with limited to no assistance from staff. Review of the corrective action was for staff to follow-up with the resident after his morning care. Review of the five-day follow-up report to the Nursing Home Program revealed no evidence of staff correction, nor identification of staff who allegedly gave the resident bed baths on the preceding four (4) days without noticing the condition of his feet or socks. Review of interdisciplinary progress notes dated 05/09/11 revealed the former director of nursing (DON) was informed of the condition of the resident's feet and stated education would be given to certified nursing assistants. Review of the former DON's plan of correction revealed that staff was to be inserviced on activities of daily living (ADL) care of residents and follow-up on residents doing self-care, to ensure residents change into clean socks. In an interview on 06/30/11 at 2:15 p.m., the corporate nurse consultant (Employee #132) reported she could find no evidence of any staff inservice having been done to address this issue. .",2014-10-01
10964,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,253,D,1,0,E59N11,". Based on family interview, observation, and staff interview, the facility failed to maintain a sanitary and comfortable environment, as evidenced by brown smears on a resident's bathroom wall, toilet paper rolls placed directly on the bathroom floor, and blood stains from a discharged resident's bed not cleaned in a timely manner. This practice affected one (1) of twenty-one (21) sampled residents. Resident identifier: #49. Facility census: 108. Findings include: a) Resident #49 During an interview with Resident #49's power of attorney (POA) on 06/27/11 at approximately 2:30 p.m., she stated the bathroom wall had brown stains behind the grab bar that looked like smears of bowel movement, and these stains had been there at least since 06/14/11 or 06/15/11 and had not been cleaned. Also, she stated Resident #49's roommate left the facility shortly after lunch today, and a bright red blood stain on the roommate's bed sheet had been left. Observation of Resident #49's bathroom, on 06/27/11 at 2:30 p.m., found brown-colored streaks of an unknown substance (measuring approximately 18 inches in length) on the wall beside the toilet. This substance was found to wipe off with a wet towel. Also, there were two (2) wrapped rolls of toilet paper stored directly on the bathroom floor. Observation of the roommate's bed sheet, at this same date / time, revealed a bright red blood stain approximately 8 cm to 10 cm in diameter, and a fly was observed flying and lighting on various surfaces in the room. Observation, on 06/27/11 at 2:50 p.m., found a nursing assistant entered the room and stripped the roommate's bed. Record review revealed a transfer sheet for the roommate dated 06/27/11 at 1:59 p.m. On 06/29/11 in the early afternoon, the medical records assistant stated that the time stamped on the transfer / discharge slip (1:59 p.m.) is the actual time the resident left the facility. During a tour with the interim director of nursing on 06/27/11 at approximately 4:00 p.m., these findings were reported to her, and she observed the brown stains on the bathroom wall and toilet paper rolls still setting on the bathroom floor. The following day, the bathroom wall was found to be clean looking and without the brown stains, and the toilet paper rolls stored on the floor were no longer present. .",2014-10-01
10965,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,280,D,1,0,E59N11,"**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 a resident who no longer received [MEDICAL TREATMENT], and for another resident whom the facility found to have received a lack of personal hygiene related to bathing of his feet. This practice affected two (2) of twenty-one (21) sampled residents. Resident identifiers: #2 and #43. Facility census: 108. Findings include: a) Resident #2 Review of Resident #2's current care plan revealed focus, goals, and interventions on pages 10 and 11 related to his requiring [MEDICAL TREATMENT] due to [MEDICAL CONDITION] (stage 5) and acute [MEDICAL CONDITION]. Review of Resident #2's hospital discharge summary, dated 06/08/11, revealed the attending nephrologist evaluated the resident and determined he did not need [MEDICAL TREATMENT], and his Permacath was removed during the hospitalization . The resident's care plan was not revised upon his return to the facility to reflect discontinuation of the [MEDICAL TREATMENT]. During an interview with the corporate nurse consultant (Employee #132) on 06/29/11, she agreed the care plan was not revised to indicate the resident does not receive [MEDICAL TREATMENT] treatments. -- b) Resident #43 Review of self-reported allegations of abuse / neglect sent to the State survey agency's Nursing Home Program dated 05/09/11 revealed Resident #43 experienced an incident where his socks were brown / black discolored, hardened, and difficult to remove; a very foul odor from his feet and socks permeated the air; filth (""toe jam"") was found between his toes; and his feet were described by employees as having crusted areas where the socks were tight, or of his feet being very white and wrinkled as if he had soaked them in water a long time. During the facility's investigation, employees gave statements attesting that this resident will dress himself if staff get his clothes out of the closet; will clean himself, but cannot bend over to take off his socks; and will sleep in his clothes. Review of the resident's current care plan (last revised on 01/03/11) revealed he requires limited assistance with dressing, grooming, and bathing. Review of the care plan revealed no revision noting this incident in May 2011 related to poor foot hygiene / cleansing, nor of interventions to prevent this from reoccurring in the future. During an interview with Employee #132 on 06/29/11, she agreed the resident's care plan was not revised to reflect this incident or of interventions to prevent this from reoccurring. .",2014-10-01
10966,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,312,E,1,0,E59N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, record review, observation, and staff interview, the facility failed to provide adequate services to maintain activities of daily living care (showers and/or bathing) for four (4) dependent residents, and failed to ensure that a dependent, incontinent resident was kept clean and free of odors. This practice affected five (5) of twenty-one (21) sampled residents. Resident identifiers: #37, #42, #60, #43, and #89. Facility census: 108. Findings include: a) Resident #37 During the initial tour of the facility in the early afternoon on 06/27/11, Resident #37 stated reported he had had no showers in the past six (6) weeks, adding that his [MEDICAL CONDITION] made him either a two (2) person lift or mechanical lift, and he believed it must be too difficult for staff to get him up to the shower. He asked this surveyor to speak to someone and have them visit him and confirm that he will receive showers at least weekly. Review of the April 2011 shower record for Resident #37 revealed no documented showers in April. Review of the May 2011 shower record for Resident #37 revealed only one (1) documented shower in May on 05/10/11. Review of the June 2011 shower record for Resident #37 revealed no documented showers in June (month-to-date). Review of the resident's minimum data set (MDS) with an assessment reference date (ARD) of 05/29/11 found, in Section G0120, the resident was totally dependent on staff for bathing. Review of his most current care plan revealed he required total assistance with bathing related to muscle weakness and included the following intervention: ""Showers / shampoo weekly and PRN (as needed)."" During a tour with the interim director of nursing (DON) on 06/27/11 at approximately 4:00 p.m., she spoke with the resident and learned of his wish for weekly showers. During an interview with the DON on 06/28/11 at approximately 4:00 p.m., she reviewed copies of the shower records showing showers were not done weekly in April, May, and June. No further information was presented prior to exit. -- b) Resident #42 During the initial tour of the facility in the early afternoon on 06/27/11, Resident #42 stated he was supposed to be showered once weekly, but he didn't know whether he was receiving a shower every week. Review of Resident #42's May 2011 shower record found only three (3) documented showers - on 05/02/11, 05/09/11, and 05/24/11. Review of Resident #42's June 2011 shower record found only one (1) documented shower on 06/10/11, and a refusal on 06/21/11. Review of the MDS with an ARD of 05/12/11 found, in Section G0120, the resident was totally dependent on staff for bathing. Review of his current care plan revealed he required total assistance with bathing; an intervention included: ""Showers weekly and PRN."" During an interview with the DON on 06/28/11, she reviewed copies of the shower records showing showers were not done weekly in May and June. No further information was presented prior to exit. -- c) Resident #60 During the initial tour of the facility in the early afternoon on 06/27/11, Resident #60 stated she was supposed to receive showers once weekly, but sometimes she would go two (2) weeks between showers, and she preferred to receive weekly showers. Review of the April 2011 shower record revealed she received only one (1) shower in April - on 04/08/11. Review of the MDS with and ARD of 06/16/11 found, in Section G0120, that she required physical help in part of the bathing activity. Review of her current care plan revealed she required total assistance with bathing; an intervention stated she was to have a ""shower / shampoo weekly"". During an interview with the DON on 06/28/11, she reviewed copies of shower records showing showers were not done weekly in April. No further information was presented prior to exit. -- d) Resident #43 Review of the April 2011 shower record revealed he received showers on 04/02/11, 04/10/11, 04/23/11, and possibly 04/29/11 and 04/30/11 (illegible). Review of the May 2011 shower record revealed he refused a shower on 05/07/11 and was already dressed; bed baths were documented as having been given on 05/03/11, 05/04/11, 05/05/11, and 05/06/11. However, review of an immediate fax reporting of allegations to the State survey agency's Nursing Home Program revealed an allegation, dated 05/08/11, stating Resident #43's socks were found to be brown and black stained with an odor, and he required hygiene to his feet and leg. Review of interdisciplinary progress notes dated 05/09/11 at 5:45 a.m. revealed a nursing assistant noticed a very foul odor from his feet and removed socks with great difficulty, finding crusted areas on his feet and leg where the sock was tight. Review of the June 2011 shower record revealed he refused a shower on 06/02/11 and 06/09/11, and there are no other documented showers from 06/01/11 through 06/29/11. Review of his current care plan revealed Resident #43 required limited assistance with dressing, grooming, and bathing; interventions included: ""Showers weekly and PRN."" During an interview with the DON on 06/28/11 at approximately 4:00 p.m., she reviewed copies of shower records showing that weekly showers were not provided in April, May, and June. No further information was presented prior to exit. -- e) Resident #89 Observation of Resident #89's room, during the initial tour of the facility at approximately 2:00 p.m. on 06/27/11, revealed a strong urine odor detected immediately upon entering the room. During an interview with a nursing assistant (Employee #69) at this time, he checked with another nursing assistant (Employee #81) who was assigned to this room, and she allegedly told him she had just completed her bed change and the urine odor was still in the air. During a tour with the DON on 06/27/11 at approximately 4 p.m., she agreed a strong urine smell could be detected upon entrance to the room; information relayed to her as reported from the employees earlier. Observation of Resident #89 on successive days of the survey found her up in the wheelchair all day on two (2) occasions with no odor detected, and lying in bed one (1) morning with no odor detected. Review of recent self-reported allegations of abuse / neglect sent to the Nursing Home Program revealed an incident occurred on 05/16/11, where evening shift staff reported finding Resident #89 smelling of urine and with urine running down the front of her legs, and a staff member reported she could smell urine by standing a few feet away from her. .",2014-10-01
10967,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,441,E,1,0,E59N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, policy review, and staff interview, the facility failed to maintain an effective infection control program, as evidenced by isolation rooms without signage directing visitors to see a nurse before entering the residents' rooms; isolation rooms with non-visible (or not easily visible) contact precautions instructions for staff and visitors to follow; an employee failing to glove or wash hands when handling a resident and her belongings while moving her from one (1) isolation room to another; improperly cohorting a resident without a specific multi-drug resistant organism (MDRO) in a room a resident who had a specific MDRO; failure to change nebulizer masks / tubing / mini-nebs at least every seven (7) days per policy; and failure to dispose of a visibly blood stained sheet in a timely manner in a room inhabited by the presence of a fly. These practices posed a potential for more than minimal harm to more than an isolated number of residents. Resident identifiers: #106, #34, #23, #2, #90, #104, #73, #84, #108, and #49. Employee identifier: #85. Facility census: 108. Findings include: a) Residents #106, #34, #23, and #2 Observations, during the initial tour of the facility in the afternoon of 06/27/11, found Resident #106, #34, #23, and #2 had isolation carts outside their rooms, but none of the four (4) rooms had signage alerting employees or visitors to see the nurse before entering the rooms, to learn any instructions they needed before or after entering the rooms to prevent contamination or spreading of organisms. Record review found Resident #106 had an infection with an MDRO. Observation found she was in a semi-private room by herself. Record review found Resident #34 had an infection with an MDRO and was in a room by herself. Record review found Resident #23 had an infection with a MDRO, and the roommate had a history of [REDACTED]. Record review found Resident #2 was in a private room and had an infection with an MDRO. During an interview with the director of nursing (DON) on the afternoon of 06/27/11, she agreed posting of precautionary signage at the isolation rooms should have been done. Subsequent observation found fluorescent green precautionary signs posted at the doors of all residents in the facility who required contact precautions. Review of a facility policy, produced by the DON on 06/28/11 at 1:40 p.m., stated this facility employed standardized precaution signs to alert staff, visitors, and residents of rooms where there is a potential exposure to infectious materials. This policy was found to have been revised January 2008. -- b) Residents #34 and #23 Initial the tour of the facility in the early afternoon on 06/27/11 found Resident #34 required contact precautions, but the signage directing staff regarding the necessary precautions to employ when caring for this resident was lying inside the isolation cart, rather than being posted visibly. Also during the initial tour, Resident #23 was found to require contact precautions, but the signage directing staff regarding necessary precautions when caring for this resident was not visibly posted; rather, it was lying flat on the top of a high cart outside her room and not easily visible. During an interview with the DON on the afternoon of 06/27/11, she agreed that precautionary signage should be visibly posted at the door of the isolation rooms rather than being inserted inside the cart or lying flat on top of a cart where it cannot be easily viewed. Consequently, the DON ordered contact precaution signage be placed on the residents' doors or walls outside their rooms, where they could be easily viewed and read. -- c) Resident #90 During the initial tour of the facility in the early afternoon of 06/27/11, Resident #90 was observed to be in contact precautions in a private room. Observation, on 06/28/11, found Resident #90 had been moved into another room with Resident #106. Record review revealed that both residents had been diagnosed with [REDACTED].#106 also had another MDRO (namely ESBL) with which Resident #90 had not been diagnosed . Record review revealed Resident #90 was moved in with Resident #106 on 06/27/11 at 10:00 p.m. per family request, according to the nurse (Employee #33) who documented the move. During an interview with the DON on 06/28/11 at approximately 1:30 p.m., she said Resident #90 was moved in with Resident #106 last evening, but the resident should not have been moved, and facility staff discovered this error today during stand-up; subsequently, they ordered that Resident #90 be moved back to her former room. Observation on 06/28/11, a few minutes following the DON interview, found staff moving Resident #90 back into her former room. Employee #90 stated staff had difficulty reaching Resident #90's medical power of attorney (MPOA) to notify of the room change, which delayed the transfer process. During an interview with a treatment nurse (Employee #35) on 06/28/11, she stated Resident #90 had a Stage II pressure ulcer to her buttock, and Resident #106 had an open would to her calf. Record review of interdisciplinary progress notes, dated 06/28/10 at 1:10 p.m., found an entry stating that Resident #90 must be moved back to her former room due to the current roommate having ESBL and Resident #90 did not; the physician and MPOA were notified of the room change. An additional note stated multiple attempts were made to contact the MPOA regarding the room change throughout the day until successful at 1:30 p.m.; the resident's situation was explained to the family, and they agreed with the room change. During an interview on 06/29/11 with the DON and Employee #133, they stated the facility's procedure was to cohort residents per policy and have the shift supervisor's approval prior to the move; they also stated Employee #133 should be consulted prior to cohorting residents with MDROs. Employee #133 produced evidence of November 2010 staff inservicing on infection control, transmission-based precautions, resident placement, discontinuing precautions, and survey issues related to MDROs. The latter (survey issues related to MDROs) specified when a resident had a MDRO, or any infection a nurse was not sure about, to call the registered nurse (RN) on call to assist with room placement. When asked about Employee #33's hire date, it was revealed her hire date was 01/12/11. Employee #133 produced a New Hire Checklist found Employee #33 received infection control orientation on 01/17/11 and 01/18/11; however, the infection control nurse (who was also the staff development employee) was on vacation this week and not available for verification of what the infection control education for new employees entailed. During an interview with Employee #66 on 06/29/11, she stated she was the RN supervisor on 06/27/11, and should have been consulted prior Resident #90's move, but she was not consulted. Interview with Employee #133 at this time found she also was not contacted prior to the transfer, and she said she should have been notified prior to the transfer. -- d) Residents #104, #73, #84, and #108 Observation during the initial tour of the facility in the early afternoon of 06/27/11 found the following residents had nebulizer equipment dated as having been changed greater than the preceding seven (7) days, and had nebulizer equipment not covered and stored in a sanitary manner: - Resident #104 was found to have a nebulizer mask dated 06/17/11, and the mask was open to the air and not covered; - Resident #73 was found to have a nebulizer mask dated as having been changed on 06/19/11, and was open to the air and not covered; - Resident #84 was found to have a nebulizer masked dated as having been changed on 06/16/11, and was open to the air and not covered; - Resident #108 was found to have a mini-neb on the floor, and the tape with the date of having been changed was torn and illegible. During a tour of the facility with the DON at approximately 4:00 p.m., she observed the above four (4) nebulizer equipment and disposed of each of them, agreeing they should have been changed every seven (7) days. Review of the facility's policy on ""Aerosolized Medication (Neb Med)"" (revised 05/2002) revealed on Page 8 to ""Change nebulizer set-up weekly"". -- e) Resident #49 During an interview with Resident #49's power of attorney (POA) on 06/27/11 at approximately 2:30 p.m., she stated Resident #49's roommate left the facility shortly after lunch, and a bright red blood stain was left on the roommate's bed sheet. Observation, on 06/27/11 at 2:30 p.m., found Resident #49's roommate's bed sheet contained a bright red blood stain measuring approximately 8 cm to 10 cm in diameter, and a fly was observed flying and lighting on various surfaces in the room. Observation, on 06/27/11 at 2:50 p.m., found a nursing assistant entered the room and stripped the roommate's bed. Record review revealed a transfer sheet for the roommate dated 06/27/11 at 1:59 p.m. Interview with the assistant medical records employee, on 06/29/11 in the early afternoon, revealed the time stamped on the transfer / discharge sheet (1:59 p.m.) was the time the resident actually left the facility. During an interview with the DON on 06/27/11 at approximately 4 p.m., this finding of a non-timely removal of a bed linen soiled with fresh blood was discussed, with no further information obtained. -- f) Employee #85 (nursing assistant) Observation, on 06/28/11 shortly after 1:30 p.m., found Employee #85 assisting with the transfer of Resident #90 from one (1) isolation room to another. During the process, Employee #85 was observed touching Resident #90 and her bed with her ungloved hands, moved oxygen supplies from the old isolation room to the new, gathered the contents of the bedside stand in the old room and placed them in a clear plastic bag to transport to the new room, carried the clear trash bag that had contained the contents of the bedside stand toward the nurse's station, then stopped at a medication cart and emptied the trash from the medication cart into the clear plastic bag, proceeded to the soiled utility room, and used her fingers on a push button code to gain entry. Upon her return from the soiled utility room to the nurse's desk, she replied that she had washed her hands in the soiled utility room, when asked about handwashing. When asked about knowing to use gloves and handwashing in rooms with contact precautions, she stated she knew to do so but had forgot. .",2014-10-01
10968,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,514,D,1,0,E59N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to document intake and output on a resident's record as evidenced by blank spaces. This practice affected one (1) of twenty-one (21) sampled residents. Resident identifier: #2. Facility census: 108. Findings include: a) Resident #2 Review of Resident #2's intake and output record following his re-admission to the facility after a hospitalization , revealed the following: - Thirty-two (32) blank spaces under the tube feeding section noting the amount of formula he received each shift from 06/09/11 through 06/28/11; - Thirty-five (35) blank spaces under the tube feeding section noting the amount of water he received each shift from 06/09/11 through 06/28/11; and - Thirty-one (31) blank spaces under the catheter section noting the amount of urine per catheter he passed each shift from 06/09/11 thorough 06/28/11. Interviews with the interim director of nursing and Employees #35 and #78 (both licensed practical nurses - LPNs), on 06/29/11 at approximately 2:00 p.m., revealed the nursing assistants turn in the intake and output records each shift to the nurse in charge of those residents, and the nurses then record the intake and outputs each shift on form 40-1042S. The intake and output records for residents are then stored in a filing cabinet at the nurse's desk for one (1) month, then are taken to medical records and boxed up. When asked about a policy related to recording intakes and outputs, the DON copied a note attached to the book where intake and output records are kept each day, which stated: ""Attention all nurses, all holes in I/O (intake and output) Book must be fixed by Monday 2/2/11. Last/Final warning ... I/O book must be complete q (every) shift. If previous shift left holes, don't take (from the) floor!"" Review of physician's orders [REDACTED].#2, nor was there a care plan focus to maintain intake and output records. Record review revealed this resident was NPO (nothing per os/mouth), received only tube feedings and water flushes through a gastrostomy tube, and had a Foley indwelling urinary catheter. .",2014-10-01
10969,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-06-30,520,D,1,0,E59N11,". Based on record review and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement plans of action to correct identified quality deficiencies related to failing to ensure residents received adequate assistance to maintain good personal hygiene. Resident identifier: #43. Facility census: 108. Findings include: a) Resident #43 Record review of an immediate fax report of allegations to the Nursing Home Program on 05/09/11 revealed facility staff reported an incident which occurred on 05/08/11, related to Resident #43 found wearing stained and malodorous socks. Review of interdisciplinary progress notes and witness statements revealed his feet and socks had a foul odor, the stench of which permeated the hallway outside the resident's room; the socks the resident was wearing were hardened, stuck to his feet, and difficult to remove. Further witness statements stated he had filth between his toes, and his feet were very white and wrinkled, having the appearance of having soaked in water a long time; Employee #19 (nursing assistant) stated this resident cannot bend over and take off his socks; Employee #97 (nursing assistant) stated he sleeps in his clothes; and Employee #38 (nursing assistant) stated he has never seen the resident in a gown. Review of the May 2011 shower record revealed he refused a shower on 05/07/11 and was already dressed; bed baths were documented as having been given on 05/03/11, 05/04/11, 05/05/11, and 05/06/11, and a partial bath was documented as having been given on 05/07/11. Review of the five-day follow-up report to the Nursing Home Program on 05/13/11 revealed the outcome of the facility's internal investigation found Resident #43 had soiled socks on 05/08/11, and had refused a shower on 05/07/11, noting he chooses to complete his own morning care with limited to no assistance from staff. Review of the corrective action was for staff to follow-up with the resident after his morning care. Review of the five-day follow-up report to the Nursing Home Program revealed no evidence of staff correction, nor identification of staff who allegedly gave the resident bed baths on the preceding four (4) days without noticing the condition of his feet or socks. Review of interdisciplinary progress notes dated 05/09/11 revealed the former director of nursing (DON) was informed of the condition of the resident's feet and stated education would be given to certified nursing assistants. Review of the former DON's plan of correction revealed that staff was to be inserviced on activities of daily living (ADL) care of residents and follow-up on residents doing self-care, to ensure residents change into clean socks. In an interview on 06/30/11 at 2:15 p.m., the corporate nurse consultant (Employee #132) reported she could find no evidence of any staff inservice having been done to address this issue and no revisions made to the resident's care plan to ensure this does not recur. (See also citations at F225, F280, and F312.)",2014-10-01
10970,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-06-29,246,E,1,0,6HEK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, resident interview, review of facility complaints, and review of resident council minutes for the months of April, May and June 2011, the facility failed to provide services with reasonable accommodation of resident needs and preferences, by failing to answer call lights in a reasonable amount of time. Random interviews with alert and oriented residents revealed it took an hour or more before staff would answered resident call lights. Review of the facility's internal complaint records and resident council meeting minutes found residents had made complaints to the facility about call lights not being answered timely. Observation, on 06/29/11 at 10:05 a.m., found a call light ringing outside of Resident #11's room. Many staff members had passed by this resident's door, and staff was seated at the nurse's station which was outside this room. No one responded to this activated call light until 10:20 a.m. This practice has the potential to affect all residents who could independently their call lights. Facility census: 89. Findings include: a) During the initial tour of the facility on 06/28/11 at 8:15 a.m., brief interviews were conducted with alert and oriented residents. Two (2) residents expressed concern about how long it took to get their call lights answered. Both residents stated it could take up to or over an hour for staff to respond. Review of the concerns / grievances received by the facility from either family members or residents disclosed complaints about call lights not being answered timely. During the month of April 2011, two (2) complaints were received by the facility about call lights not being answered timely; during the month of May 2011, one (1) resident complained about staff not answering the call light answered timely. Resident council minutes were reviewed for the months of April, May, and June 2011. During the May meeting, one (1) resident had complained about not getting call lights answered timely and four (4) other residents agreed that call lights were not being answered timely. Observations in the facility, on 06/29/11 at 10:05 a.m., found a call light was ringing outside of Resident #11's room. When the observation began, the call light was already on and the room door was closed. Resident #11's room was beside the nurse's station at the end of the hall. The call light was answered at 10:20 a.m.; however, during the observation period, many nursing staff members passed by the door, and staff was seated in the nurse's station just outside the room; none of these individuals looked into the room or answered the light. After the call light was answered and staff left the room, this surveyor entered the room and discovered Resident #11 was the only resident in the room at this time. Resident #11 stated she was not feeling well and needed assistance. The resident was noted to be non-ambulatory and required a special call light that she could activate by moving her hand against it. Medical record review disclosed Resident #11 had [MEDICAL CONDITION] and was receiving hospice services. The resident was unable to get out of bed and no other means of requesting assistance when needed. During an interview with the administrator and the director of nursing on 06/29/11 at 11:30 a.m., they were informed of the above observation,",2014-10-01
10971,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2011-06-02,157,D,1,0,9FE011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, facility record review, and staff interview, the facility failed to notify the family member / legal representative of one (1) of five (5) sampled residents (who recently passed away), when a significant change in a resident's physical condition occurred and a new and/or altered treatment was ordered by the physician. Resident identifier: #102. Facility census: 100. Findings include: a) Resident #102 Review of Resident #102's closed record found a nursing note, dated [DATE] at 6:50 p.m., stating Resident #102 developed a fever of 101.3 degrees Fahrenheit, his oxygen saturation level was low at ,[DATE]%, and his lung sounds were diminished. The physician was notified by the registered nurse (RN - Employee #54), but there was no evidence the resident's medical power of attorney representative (MPOA) had been notified. In a telephone interview with Employee #54 on [DATE] at 11:30 a.m., the RN revealed that Resident #102 experienced a change of condition on [DATE] at 6:50 p.m., whereby he developed a fever and his lungs sounded congested. She said she notified the physician via fax at 6:50 p.m., and then got busy while awaiting the physician's response. Then it got late, so she did not call the MPOA. Her shift ended at 10:00 p.m., and she gave a report of his condition change to the night shift RN (Employee #69). The physician faxed orders to the facility at 10:30 p.m., after her shift had ended. Review of a physician order [REDACTED]. In an interview on [DATE] at 2:30 p.m., Employee #69 confirmed she was on duty at 10:30 p.m. on [DATE] when the physician's orders [REDACTED]. When asked if she called the MPOA of the new order for the chest x-ray to be done the following morning, she stated that she normally does not call people late at night unless something really bad is going on, and she did not want to alarm the family, so she did not call the MPOA about the new order. She said she was completely shocked that Resident #102 passed away on [DATE]; his death was not expected. Review of Nurse's Notes dated [DATE] at 1:35 p.m. revealed Licensed Practical Nurse (LPN) #53 assessed Resident #102 as having a low oxygen saturation level of 82- 84% on room air and 93% on 2 (two) liters of oxygen; unable to eat; not responding; lethargic; temperature 100 degrees; no signs or symptoms of shortness of breath or distress noted. During an interview on [DATE] at 2:15 p.m., a licensed practical nurse (LPN - Employee #53) recalled having told an RN on [DATE] that Resident #102 was not doing well, but she did not recall which RN she told. She described Resident #102 on [DATE] as being pale, using oxygen, having no intravenous fluids. She said, in the morning, he had a chest x-ray and he seemed fine, although he was sleeping a lot and had a fever; he had no shortness of breath even when his his oxygen saturation level was at 82% on room air. She said the oxygen concentrator was already in his room, so she began oxygen at 2 liters per minute per nasal canula. She explained that his oxygen level would drop sometimes even when he was not sick. She said staff just happened to check the oxygen saturation level that day, but for no particular reason that she recalled. Review of a physician's orders [REDACTED].#111), revealed a new order for an antibiotic, [MEDICATION NAME] nebulizer treatments three (3) times daily for five (5) days, to check his temperature every shift for the next twenty-four (24) hours then daily while on the antibiotic, and recheck the chest x-ray in three (3) weeks. In an interview on [DATE] at 10:10 a.m., Employee #111 revealed she was the day shift supervisor on [DATE]. She said she did not recall Employee #53 telling her that Resident #102 was fevered or had lowered oxygen saturation levels. She stated she received the chest x-ray results that morning and immediately faxed the report to the physician. She acknowledged that she received orders from the physician at 1:45 p.m. on [DATE] for antibiotic therapy, [MEDICATION NAME] nebulizer treatments, temperature monitoring, and to repeat the chest x-ray in three (3) weeks. She said she passed that information along to the oncoming RN supervisor (Employee #54), as her own shift ended at 2:00 p.m. She said she did not recall telling Employee #54 anything about family notification, but she recalled that Employee #54 told her she would go in and check Resident #102. She said she was shocked to learn the following day that Resident #102 had expired on [DATE], noting his death was unexpected. In an interview on [DATE] at 11:30 a.m., Employee #54 stated she reported to work at 2:00 p.m. on [DATE]. She stated Employee #111 had received orders from the physician at 1:45 p.m. (around the change of shift) on [DATE]. She did not recall whether Employee #111 left out the 1:45 p.m. physician order [REDACTED]. She said when she called the family at 4:30 p.m. on [DATE] to report that Resident #102 had expired, it was then that she realized the family had not been notified of his condition change. She said, normally, nurses notify the family of condition changes, new orders, and changes in treatments, but this was not the case this time due to miscommunication among staff. Review of a grievance / complaint report dated and signed on [DATE], and produced by the director of nursing (DON) on [DATE] at 3:10 p.m., acknowledged that Resident #102's MPOA reported she was not notified in a timely manner of a significant change in condition with Resident #102, and she felt she could have spent the last moments with him had she been notified her in a timely manner at 6:50 p.m. on [DATE]. Attached to the complaint was an Employee Education Document noting this form was being completed to offer support of education provided to Employee #111. A description of the education being provided to this employee regarded notification of family / MPOA when there is a significant change with a resident; it noted the physician was notified in this case, but the MPOA was not notified. During an interview on [DATE] at 10:00 a.m., the DON said she was unable to find a policy related to family notifications of significant changes, but she found a ""Bill of Rights"" in-service handout that the licensed social worker (LSW) presents annually, and most recently presented to nursing staff on [DATE]. She said, in part, this handout states the facility shall immediately inform the resident and consult with the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status. Also, she produced a copy of the RN supervisor's job description. On page 2, the duties were found to include: ""Contact POA (Power of Attorney) or appropriate family member when there is a change in Resident's condition."" When interviewed on [DATE] at 12:40 p.m., the LSW (Employee #52) revealed that significant change care plan meetings are held if a resident is terminal or declining, and the option of hospice is discussed. She stated if there is a decline in a resident, the family should be notified. She said she thought that Resident #102's MPOA should have been notified of a change in condition when it occurred that weekend in April. She looked at the inservice handout on ""Bill of Rights"" and acknowledged that she gave that inservice on [DATE], and that it was given every year for nursing staff. .",2014-10-01
10972,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2011-06-02,514,D,1,0,9FE011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to transcribe accurately on a Medication Administration Record [REDACTED]. This was observed for one (1) of seven (7) sampled residents. Resident identifier: #102. Facility census: 100. Findings include: a) Resident #102 Record review revealed a physician's orders [REDACTED].#102 to have [MEDICATION NAME] nebulizer treatments three (3) times daily for five (5) days. Review of the MAR for Resident #102 revealed the order for [MEDICATION NAME] nebulizer treatments was transcribed to be given three (3) times daily for five (5) days at 8:00 a.m., 12:00 p.m., and 4:00 p.m. Review of the MAR indicated [REDACTED]. Also, the arrow was drawn for the first 8:00 a.m. dose to begin on [DATE], nearly six (6) hours before the order was written. Because the resident expired at 4:30 p.m. on [DATE], and the facility has a one (1) hour window before and after a dose of medication is scheduled to be given, it could not be determined whether a medication error occurred.",2014-10-01
10973,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,323,E,1,0,K8MG11,". Based on observation, staff interview, and resident interview, the facility failed, for four (4) of sixteen (16) sampled residents, to ensure the residents' environment remained free as possible of accident hazards, as evidenced by air conditioning units in the rooms of Residents #24, #84, #120 and #48 leaking water onto the floor. Resident identifiers: #24, #84, #120 and #48. Facility census: 116. Findings include: a) Residents #84 and #24 On 06/29/11 at 3:00 p.m., two (2) surveyors and the facility's maintenance director (Employee #24) were in the room shared by Residents #84 and #24, where a white blanket was observed under the air conditioning unit. The maintenance director said the bath blanket was there to absorb the water leaking from the air conditioner. He also stated, ""All staff on all shifts were inserviced to monitor the blanket and change it as needed."" He stated, ""The unit leaks because it is not level."" The water leaking from the air conditioning unit in this room drained toward the resident's bedside stand. The floor had a black residue on it which the maintenance director said ""was not mold"". The paint above the baseboard was bubbled. The blanket under the air conditioning unit was wet and had rust-colored marks on it. Resident #84 stated, ""It (the air conditioning unit) has been draining for 2 to 3 weeks."" Resident #84 denied getting out of bed on the side where the air conditioning unit is located. She also denied experiencing a fall due to water on the floor. During this same interview, Resident #24, the roommate of Resident #84, denied having any problems with water in the floor. -- b) Residents #48 and #120 Both surveyors interviewed Resident #48 (in a room shared with Resident #120) regarding the air conditioning unit in her room at approximately 2:30 p.m. on 06/29/11. Resident #48 stated, ""It (air conditioning unit) leaks into the bathroom, and there has been water in the floor."" The resident denied having fallen because of water in the floor. -- c) During the interview with the maintenance director, he stated, ""If you think this is bad, the 200 Hall has the same problem."" A surveyor immediately went to the 200 Hall and checked each resident room for any leaking air conditioning unit. No units were found to be leaking. The maintenance director explained this problem is worse when the outdoor temperature is higher. .",2014-10-01
10974,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,465,E,1,0,K8MG11,". Based on observation, staff interview, and resident interview, the facility failed, for four (4) of sixteen (16) sampled residents, to provide a safe, functional, sanitary, and comfortable environment, as evidenced by air conditioning units in the rooms of Residents #24, #84, #120 and #48 leaking water onto the floor. Resident identifiers: #24, #84, #120 and #48. Facility census: 116. Findings include: a) Residents #84 and #24 On 06/29/11 at 3:00 p.m., two (2) surveyors and the facility's maintenance director (Employee #24) were in the room shared by Residents #84 and #24, where a white blanket was observed under the air conditioning unit. The maintenance director said the bath blanket was there to absorb the water leaking from the air conditioner. He also stated, ""All staff on all shifts were inserviced to monitor the blanket and change it as needed."" He stated, ""The unit leaks because it is not level."" The water leaking from the air conditioning unit in this room drained toward the resident's bedside stand. The floor had a black residue on it which the maintenance director said ""was not mold"". The paint above the baseboard was bubbled. The blanket under the air conditioning unit was wet and had rust-colored marks on it. Resident #84 stated, ""It (the air conditioning unit) has been draining for 2 to 3 weeks."" Resident #84 denied getting out of bed on the side where the air conditioning unit is located. She also denied experiencing a fall due to water on the floor. During this same interview, Resident #24, the roommate of Resident #84, denied having any problems with water in the floor. -- b) Residents #48 and #120 Both surveyors interviewed Resident #48 (in a room shared with Resident #120) regarding the air conditioning unit in her room at approximately 2:30 p.m. on 06/29/11. Resident #48 stated, ""It (air conditioning unit) leaks into the bathroom, and there has been water in the floor."" The resident denied having fallen because of water in the floor. -- c) During the interview with the maintenance director, he stated, ""If you think this is bad, the 200 Hall has the same problem."" A surveyor immediately went to the 200 Hall and checked each resident room for any leaking air conditioning unit. No units were found to be leaking. The maintenance director explained this problem is worse when the outdoor temperature is higher.",2014-10-01
10975,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,166,D,1,0,K8MG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the complaint / concern and abuse files, the facility failed to make prompt efforts to resolve the grievances voiced by or on behalf of residents, including those with respect to the behavior of other residents, for one (1) of fourteen (14) sampled residents whose family filed a complaint. On 05/31/11, Resident #95's family member voiced a complaint to staff regarding Resident #95's fear of her roommate (Resident #119), and the facility did not make prompt efforts to address these concerns. Resident #119's abusive behaviors toward others (including Resident #95) continued until 06/02/11, when Resident #119 threw an object at Resident #95, and Resident #95 sustained a laceration requiring emergency room (ER) treatment. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - ""Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor."" - On 05/31/11 at 3:15 p.m. - ""Roommates continue to argue. Assisted resident to nurses desk to ensure safety."" - On 05/31/11 at 5:20 p.m. - ""Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict."" - On 06/02/11 at 7:00 a.m. - ""Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval. "" On a change in condition documentation form dated 06/02/11 was written (quoted as written): "" 6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures. "" - On 06/02/11 at 12:00 p.m. - "" Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches. "" --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). -- 2. Further review Resident #119 ' s medical record found multiple entries in her nursing notes documenting the resident ' s physically and verbally abusive behavior toward staff and other residents (including Resident #95) leading up to Resident #119 ' s admission to the hospital for inpatient psychiatric services on 05/11/11. Upon her return to the facility following this hospitalization on [DATE], Resident #119 was readmitted to the same room with Resident #95. Resident #119 ' s abusive behaviors toward others (including her roommate) continued - including incidents of physical aggression toward Resident #95 on 05/31/11 - until she was readmitted to the hospital for inpatient psychiatric services on 06/02/11. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found the following entries (quoted as written): - On 05/24/11 at 4:15 p.m. - "" admitted to skilled services of Dr. (name) for care ... "" - On 05/25/11 at 6:50 a.m. - "" Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid ' s faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roommate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident. "" - On 05/25/11 at 1:50 p.m. - ""Throwing Objects @ (at) Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up. "" - 05/26/11 at 10:00 a.m. - "" Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor. "" - 05/26/10 at 9:50 p.m. - "" ... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out. "" - 05/26/11 at 11:50 p.m. - "" Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor."" - 05/27/11 at 8:00 a.m. - "" ... Has been combative /c staff since re-admit from psyche. ... "" - 05/27/11 at 10:15 a.m. - "" Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician."" - 05/28/11 at 10:00 a.m. - "" Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor. "" - 05/30/11 at 9:00 a.m. - "" Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM. "" - 05/30/11 at 1:00 p.m. - "" Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway. "" - 05/30/11 at 1:15 p.m. - "" Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her. "" - 05/30/11 at 1:30 p.m. - "" Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members. "" - 05/30/11 at 4:10 p.m. - "" Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident. "" - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway. "" - 05/30/11 at 10:00 p.m. - "" Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor. "" - 05/30/11 at 11:30 p.m. - "" Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor. "" - 06/02/11 at 12:30 p.m. - "" N/O noted to send (hospital) ER for medical clearance for psych family aware. "" - 06/02/11 at 1:00 p.m. - "" OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych. "" --- c) An interview on 06/28/11 at 10:00 a.m. the administrator reviewed the nursing notes for Resident #95 for 05/31/11 and denied any prior knowledge of the grievance made on behalf of Resident #95 or the incidents reflected in the nursing notes for that day. He provided a statement, on 06/28/11 at 4:40 p.m., to include this same information. -- d) In an interview with Resident #95's daughter on 06/28/11 at 4:15 p.m., she confirmed having filled out a report on 05/31/11 regarding her mother's roommate (Resident #119) standing over her, ""pulling her hair"", and saying, ""You stole my husband."" She and the nurse (Employee #41) and took the report to the social worker (Employee #39). According to the daughter, Employee #39 told her they were full to capacity and there was no where to put her. She said the administrator called her at 7:30 a.m. on 06/28/11 and wanted to discuss this with her, and she came into the facility and spoke with him. -- e) Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statement obtained by the facility from the social worker on 06/28/11: ""I was not aware of an incident where resident's roommate had her hands around her neck and was yelling at resident. I was also not aware of an incident on the same day that an empty coffee cup was thrown at resident. Resident's daughter had talked about a room change based on cognitive functioning of the resident's roommate prior to the incident on 6-2-11. ..."" Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statements obtained by the facility on 06/28/11, all of whom attested to hearing Resident #95 ' s daughter expressing concerns about Resident #95 alleging to the daughter that her roommate (Resident #119) had tried to choke her (all quoted as written): - Employee #106 (medical records) - ""I was at the fax machine at Maple. (Resident #95's) daughter come to the desk & told (Employee #41) the nurse 'I don't know if this is true or not but mother said roommate tried to choke her last night.' (Employee #41) said would you like to file a grievance. (Employee #41) asked me for one. I couldn't find 1 so (Employee #108) reached into file cabinet & handed the grievance to the daughter. The daughter sat in the chair & (Employee #108) told her how to fill it out. She filled it out and asked what to do /c (with) it. (Employee #41) said to give to social worker. Daughter asked where that is & (Employee #41) said I will show you. (Employee #41) brought the daughter around the hallway towards social service office. Later on that day I asked her if she documented on it & told her she needed to. I asked her what the outcome was & she said the daughter said (Employee #39) said there were no empty beds."" - Employee #108 (licensed practical nurse - LPN) - ""Standing at nurses station on May 31, 2011. Dau (daughter) comes up to NS (nurses' station) & said that her mother had told that her room mate had choked her. I 'do not know if it really happened or not.' but mother is terrorized of her room mate. Gave her a grievance form to fill out. Hall nurse brought dau up to talk with (Employee #39). Came back to floor and said (Employee #39) had told her them we were full and could not do a room change."" -- f) Confidential interviews with staff, conducted in the presence of two (2) nurse surveyors on 06/28/11, revealed that, when Resident #119 was ready to return from the hospital for inpatient psychiatric care on 05/24/11, staff expressed concern to the admission coordinator that Resident #119 should not be returned to the room occupied by Resident #95, due to concerns for Resident #95 ' s safety. Confidential interviews with staff also revealed that the daughter ' s report, on 05/31/11, of her concerns about Resident #119 ' s behavior toward Resident #95 were discussed in one (1) or more morning stand-up meetings prior to 06/02/11, when Resident #95 sustained injuries after being hit in the forehead by an object thrown by Resident #119. The facility was aware of Resident #119 ' s abusive behaviors toward others (including Resident #95) and failed to implement measures to protect Resident #95 from harm. (See also citation at F224.) .",2014-10-01
10976,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,224,G,1,0,K8MG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, review of the facility's internal investigations into allegations of abuse / neglect, and confidential staff interviews, the facility failed to provide services to one (1) of fourteen (14) sampled residents to protect the resident from physical harm. Resident #119, who exhibited physically and verbally abusive behaviors towards others, was admitted for inpatient psychiatric care on 05/11/11. Prior to this hospitalization , she had shared a room with Resident #95 and had directed some of her abusive behaviors towards this roommate. Prior to her return, nursing staff expressed concern to administrative personnel that Resident #95 was not able to defend herself against Resident #119, and that Resident #119 should not be returned to the same room. When Resident #119 returned from a psychiatric unit to the facility on [DATE], she was placed in the same room as Resident #95. On 05/31/11, Resident #95's daughter voiced a concern to nursing staff, reporting that Resident #95 had told her she awoke that morning with Resident #119 standing over Resident #95's bed with her hands around her throat and making verbal threats to her. This concern was also reported to the facility's social worker that same day. Later in the day on 05/31/11, Resident #119 threw a cup at Resident #95. On 06/02/11, Resident #119 threw an object at Resident #95 resulting in a laceration to Resident #95's forehead, which required emergency room (ER) treatment. Administrative personnel were aware of Resident #119's physically and verbally abusive behaviors toward others (including her roommate) and failed to implement measures to protect Resident #95 from harm. Resident identifiers: #95 and #119. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - ""Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor."" - On 05/31/11 at 3:15 p.m. - ""Roommates continue to argue. Assisted resident to nurses desk to ensure safety."" - On 05/31/11 at 5:20 p.m. - ""Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict."" - On 06/02/11 at 7:00 a.m. - ""Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c (with) a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval."" On a change in condition documentation form dated 06/02/11 was written (quoted as written): ""6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures."" - On 06/02/11 at 12:00 p.m. - ""Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches."" --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). Review of her most recent comprehensive MDS, an annual assessment with an ARD of 11/23/10, revealed in Section E that, during the assessment reference period ending on 11/23/10, the resident did not exhibit any behavioral symptoms. Review of an abbreviated quarterly MDS with an ARD of 02/23/11 found in Section E that, during that assessment reference period ending on 02/23/11, the resident again did not exhibit any behavioral symptoms. -- 2. Further review Resident #119's medical record found the following nursing notes from 04/13/11 through 05/11/11 (quoted as written): - On 04/13/11 at 6:30 p.m. - ""Resident sitting in lobby and will not come to her room. States someone is coming to meet her."" On a change in condition documentation form dated 04/13/11 at 8:00 p.m. was written: ""8pm Resident continues to remain in lobby & make attempts to go outside. CNA has been assigned to do one-on-one supervision. Call to Dr. (name) @ this x (time). 8:20pm Dr. (name) made aware of resident exit seeking & staying in lobby. Order for [MEDICATION NAME] 0.5 mg PO (by mouth) q6(symbol for 'hours') (every six hours) for exit seeking , yelling, resisting care. MPOA (name) made aware of status & new order. 10:15pm Resident back in room @ this time. Will monitor for further behaviors. ..."" - On 04/19/11 at 11:00 a.m., 04/25/11 at 6:00 p.m., 04/26/11 at 10:00 a.m., and 04/27/11 at 9:50 a.m., nurses documented that the resident refused all medications and that the attending physician was aware. - On 04/27/11 at 2:00 p.m. - ""Dr. (name) in facility @ this time. New order [MEDICATION NAME] 4.6 mg q24hrs (every twenty-four hours). (Name of MPOA) notified."" - On 04/27/11 at 10:45 p.m. - ""Resident combative /c (with) nurse when [MEDICATION NAME] applied, /c hitting & yelling."" - On 04/30/11 at 10:00 a.m. - ""Refused all AM (morning) meds MD aware."" - On 05/03/11 at 10:30 a.m. - ""Resident has (arrow up) agitation, yelling, going thru roommates belongings, going thru belongings of resident in room (#). Staff attempting to redirect still continues behavior. [MEDICATION NAME] given at this time."" - 05/04/11 at 03:00 p.m. - ""Gave PRN (as needed) [MEDICATION NAME] earlier this shift d/t (due to) anxiety AEB (as evidence by) hitting, yelling & refusing care. Effective at this time. ..."" - 05/07/11 at 05:00 a.m. - ""N/O (new order) written for appt (appointment) to be scheduled /c (hospital) for psych eval per Dr. (name) on 5/4/11 at 8pm."" - 05/07/11 at 6:35 a.m. - ""Res (arrow up) in w/c (wheelchair) in Activities at door pushing on bar. This nurse attempted to move res w/c from door et (and) res grabbed this nurses arm et bit (L) (left) forearm. Res then grabbed the flowers on decorative tree, pulling them. Res reached over to table et pulled tablecloth off et threw it in the floor. Then began propelling her w/c to several more table, pulling off table clothes et throwing them into floor. Res then exits Activities room into hallway et goes into her room et gets into bed."" - 05/07/11 at 09:30 a.m. - ""... Gave PRN [MEDICATION NAME] this AM d/t anxiety AEB hitting staff, throwing waste on staff and unable to redirect. Did take PO medication this AM /s (without) difficulty, but them threw water on 100 hall nurse. [MEDICATION NAME] effective at this time. ..."" - 05/08/11 at 9:30 a.m. - ""Resting in bed. Anxiety noted this AM AEB hitting, throwing cups /c water. Attempted redirection /s success, gave PRN [MEDICATION NAME] this AM. Effective at this time. ..."" - 05/08/11 at 8:00 p.m. - ""Walked into residents room to give meds. Resident sat up in bed and knocked cup of pills out of LPN's hand. ..."" - 05/09/11 at 8:00 a.m. - ""Resident has (arrow up) anxiety this AM. Removing clothes, throwing objects in room. [MEDICATION NAME] given this AM."" - 05/09/11 at 10:00 a.m. - ""[MEDICATION NAME] effective. Spoke /c Dr. (name). N/O CBC (complete blood count) / BMP (basic metabolic panel) / UA (urinalysis) C&S (culture and sensitivity) in AM. MPOA aware."" - 05/09/11 at 4:00 p.m. - ""Refused all meds @ this time attempt x 3."" - 05/10/11 at 02:30 a.m. - ""Resident combative hitting, slapping staff. Refusing straight cath. quote, 'You all are not nurses, get out, get out, I'm not letting you look at me your trash.' Unable to obtain cath for UA C &S."" Addendum: ""Resident began screaming, help help."" - 05/10/11 at 4:00 a.m. - ""Labs drawn for CBC, BMP (R) (right) AC (antecubital) By lab tech. Resident again refusing straight cath for UA C&S asked resident if go to restroom and void resident refused. ..."" - 05/10/11 at 9:00 a.m. - ""Resident refused all meds this AM ... Resident refuses to dress, wearing only robe. Attempt x 3 to cath for urine she continues to refuse."" - 05/10/11 at 11:00 a.m. - ""Staff attempting to straight cath resident /s success. She is hitting staff in face / slapping staff / kicking staff. ..."" - 05/10/11 at 5:00 p.m. - ""Refused all meds attempt x 3."" - 05/11/11 at 3:30 a.m. - ""UA obtained via straight cath method D/T (due to) behaviors."" - 05/11/11 at 8:40 p.m. - ""Resident out to (hospital) ER for direct admit to psyche unit D/T behaviors. ..."" - Review of Resident #119's care plan dated 02/24/11 found the following handwritten entries dated 05/09/11 (quoted as written): Focus: ""Behaviors of hitting, biting throwing items."" Goals: ""(Arrow down) Episodes of behaviors. Will not hurt self or others."" Interventions: ""1) MD to look at meds. 2) Offer activities appropriate for resident. 3) Labs per orders. 4) Psyche consult."" - A confidential interview with staff, in the presence of two (2) nurse surveyors on 06/28/11, revealed that, prior to her hospitalization on [DATE], Resident #119 had lived at the facility for years and had never acted like this before. No comprehensive assessment was conducted to address this significant change in Resident #119's behavior. -- 3. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found (quoted as written): - On 05/24/11 at 4:15 p.m. - ""admitted to skilled services of Dr. (name) for care ..."" - On 05/25/11 at 6:50 a.m. - ""Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid's faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roommate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident."" - On 05/25/11 at 1:50 p.m. - ""Throwing Objects @ Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up."" - 05/26/11 at 10:00 a.m. - ""Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor."" - 05/26/10 at 9:50 p.m. - ""... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out."" - 05/26/11 at 11:50 p.m. - ""Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor."" - 05/27/11 at 8:00 a.m. - ""... Has been combative /c staff since re-admit from psyche. ..."" - 05/27/11 at 10:15 a.m. - ""Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician."" - 05/28/11 at 10:00 a.m. - ""Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor."" - 05/30/11 at 9:00 a.m. - ""Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM."" - 05/30/11 at 1:00 p.m. - ""Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway."" - 05/30/11 at 1:15 p.m. - ""Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her."" - 05/30/11 at 1:30 p.m. - ""Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members."" - 05/30/11 at 4:10 p.m. - ""Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident."" - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway."" - 05/30/11 at 10:00 p.m. - ""Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor."" - 05/30/11 at 11:30 p.m. - ""Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor."" - 06/02/11 at 12:30 p.m. - ""N/O noted to send (hospital) ER for medical clearance for psych family aware."" - 06/02/11 at 1:00 p.m. - ""OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych."" -- 4. Review of the May 2011 MAR for PRN medications found the following entries: - On 05/25/11 at 1:50 p.m. - [MEDICATION NAME] was administered for ""Throwing Objects @ Roomt (roommate)"" - On 05/29/11 at 1:00 p.m. - [MEDICATION NAME] was administered for ""Throwing objects@ people, yelling, walking down hall naked"" - On 05/30/11 at 11:20 p.m. - [MEDICATION NAME] was administered for ""throwing objects at roommate, hitting staff, yelling in hallway"" -- 5. Review of Resident #119's care plan dated 05/25/11 revealed the following entries: Focus: ""Hx of Resisting treatment / care AEB refusing showers, refusing ADL's (activities of daily living), related to: Cognitive Impairment / dementia, unspecified [MEDICAL CONDITION]."" An undated handwritten addendum to this focus was ""AEB, Hitting staff throwing items."" Goals: ""Resident will comply with care routine, showers and ADLs."" Interventions: ""Administer medication for cognition as ordered. Document care being resisted on behavior monitoring flow sheet. If resident refused care, leave resident and return in 5-10 minutes. Praise / reward resident for demonstrating consistent desired / acceptable behavior."" All of these interventions were dated as having been created on 06/29/10. An undated handwritten addendum to this list of interventions was ""[MEDICATION NAME] as ordered."" Review of the aforementioned nursing notes from 04/13/11 through 05/11/11 revealed the interventions that had been in place since 06/29/10 were not effective in addressing the resident's behaviors, and no new interventions (e.g., increased staff supervision) were added - beyond the administration of [MEDICATION NAME] ""as ordered"" - to address this resident's physically / verbally abusive behaviors toward staff and other residents (including her roommate). --- c) An interview on 06/28/11 at 10:00 a.m. the administrator reviewed the nursing notes for Resident #95 for 05/31/11 and denied any prior knowledge of the grievance made on behalf of Resident #95 or the incidents reflected in the nursing notes for that day. He provided a statement, on 06/28/11 at 4:40 p.m., to include this same information. -- d) In an interview with Resident #95's daughter on 06/28/11 at 4:15 p.m., she confirmed having filled out a report on 05/31/11 regarding her mother's roommate (Resident #119) standing over her, ""pulling her hair"", and saying, ""You stole my husband."" She and the nurse (Employee #41) and took the report to the social worker (Employee #39). According to the daughter, Employee #39 told her they were full to capacity and there was no where to put her. She said the administrator called her at 7:30 a.m. on 06/28/11 and wanted to discuss this with her, and she came into the facility and spoke with him. -- e) Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statement obtained by the facility from the social worker on 06/28/11 (quoted as written): ""I was not aware of an incident where resident's roommate had her hands around her neck and was yelling at resident. I was also not aware of an incident on the same day that an empty coffee cup was thrown at resident. Resident's daughter had talked about a room change based on cognitive functioning of the resident's roommate prior to the incident on 6-2-11. ..."" Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statements obtained by the facility on 06/28/11, all of whom attested to hearing Resident #95 ' s daughter expressing concerns about Resident #95 alleging to the daughter that her roommate (Resident #119) had tried to choke her (all quoted as written): - Employee #106 (medical records) - ""I was at the fax machine at Maple. (Resident #95's) daughter come to the desk & told (Employee #41) the nurse 'I don't know if this is true or not but mother said roommate tried to choke her last night.' (Employee #41) said would you like to file a grievance. (Employee #41) asked me for one. I couldn't find 1 so (Employee #108) reached into file cabinet & handed the grievance to the daughter. The daughter sat in the chair & (Employee #108) told her how to fill it out. She filled it out and asked what to do /c (with) it. (Employee #41) said to give to social worker. Daughter asked where that is & (Employee #41) said I will show you. (Employee #41) brought the daughter around the hallway towards social service office. Later on that day I asked her if she documented on it & told her she needed to. I asked her what the outcome was & she said the daughter said (Employee #39) said there were no empty beds."" - Employee #108 (licensed practical nurse - LPN) - ""Standing at nurses station on May 31, 2011. Dau (daughter) comes up to NS (nurses' station) & said that her mother had told that her room mate had choked her. I 'do not know if it really happened or not.' but mother is terrorized of her room mate. Gave her a grievance form to fill out. Hall nurse brought dau up to talk with (Employee #39). Came back to floor and said (Employee #39) had told her them we were full and could not do a room change."" -- f) Confidential interviews with staff, conducted in the presence of two (2) nurse surveyors on 06/28/11, revealed that, when Resident #119 was ready to return from the hospital for inpatient psychiatric care on 05/24/11, staff expressed concern to the admission coordinator that Resident #119 should not be returned to the room occupied by Resident #95, due to concerns for Resident #95's safety. Confidential interviews with staff also revealed that the daughter's report, on 05/31/11, of her concerns about Resident #119's behavior toward Resident #95 were discussed in one (1) or more morning stand-up meetings prior to 06/02/11, when Resident #95 sustained injuries after being hit in the forehead by an object thrown by Resident #119. The facility was aware of Resident #119's abusive behaviors toward others (including Resident #95) and failed to implement measures to protect Resident #95 from harm. .",2014-10-01
10977,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,280,D,1,0,K8MG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to review and revise the care plan for one (1) of fourteen (14) residents (#119) who exhibited aggressive behaviors toward her roommate (#95). Resident identifiers: #95 and #119. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - ""Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor."" - On 05/31/11 at 3:15 p.m. - ""Roommates continue to argue. Assisted resident to nurses desk to ensure safety."" - On 05/31/11 at 5:20 p.m. - ""Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict."" - On 06/02/11 at 7:00 a.m. - ""Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c (with) a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval."" On a change in condition documentation form dated 06/02/11 was written (quoted as written): ""6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures."" - On 06/02/11 at 12:00 p.m. - ""Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches."" --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). Review of her most recent comprehensive MDS, an annual assessment with an ARD of 11/23/10, revealed in Section E that, during the assessment reference period ending on 11/23/10, the resident did not exhibit any behavioral symptoms. Review of an abbreviated quarterly MDS with an ARD of 02/23/11 found in Section E that, during that assessment reference period ending on 02/23/11, the resident again did not exhibit any behavioral symptoms. -- 2. Further review Resident #119's medical record found the following nursing notes from 04/13/11 through 05/11/11 (quoted as written): - On 04/13/11 at 6:30 p.m. - ""Resident sitting in lobby and will not come to her room. States someone is coming to meet her."" On a change in condition documentation form dated 04/13/11 at 8:00 p.m. was written: ""8pm Resident continues to remain in lobby & make attempts to go outside. CNA has been assigned to do one-on-one supervision. Call to Dr. (name) @ this x (time). 8:20pm Dr. (name) made aware of resident exit seeking & staying in lobby. Order for [MEDICATION NAME] 0.5 mg PO (by mouth) q6(symbol for 'hours') (every six hours) for exit seeking , yelling, resisting care. MPOA (name) made aware of status & new order. 10:15pm Resident back in room @ this time. Will monitor for further behaviors. ..."" - On 04/19/11 at 11:00 a.m., 04/25/11 at 6:00 p.m., 04/26/11 at 10:00 a.m., and 04/27/11 at 9:50 a.m., nurses documented that the resident refused all medications and that the attending physician was aware. - On 04/27/11 at 2:00 p.m. - ""Dr. (name) in facility @ this time. New order [MEDICATION NAME] 4.6 mg q24hrs (every twenty-four hours). (Name of MPOA) notified."" - On 04/27/11 at 10:45 p.m. - ""Resident combative /c (with) nurse when [MEDICATION NAME] applied, /c hitting & yelling."" - On 04/30/11 at 10:00 a.m. - ""Refused all AM (morning) meds MD aware."" - On 05/03/11 at 10:30 a.m. - ""Resident has (arrow up) agitation, yelling, going thru roommates belongings, going thru belongings of resident in room (#). Staff attempting to redirect still continues behavior. [MEDICATION NAME] given at this time."" - 05/04/11 at 03:00 p.m. - ""Gave PRN (as needed) [MEDICATION NAME] earlier this shift d/t (due to) anxiety AEB (as evidence by) hitting, yelling & refusing care. Effective at this time. ..."" - 05/07/11 at 05:00 a.m. - ""N/O (new order) written for appt (appointment) to be scheduled /c (hospital) for psych eval per Dr. (name) on 5/4/11 at 8pm."" - 05/07/11 at 6:35 a.m. - ""Res (arrow up) in w/c (wheelchair) in Activities at door pushing on bar. This nurse attempted to move res w/c from door et (and) res grabbed this nurses arm et bit (L) (left) forearm. Res then grabbed the flowers on decorative tree, pulling them. Res reached over to table et pulled tablecloth off et threw it in the floor. Then began propelling her w/c to several more table, pulling off table clothes et throwing them into floor. Res then exits Activities room into hallway et goes into her room et gets into bed."" - 05/07/11 at 09:30 a.m. - ""... Gave PRN [MEDICATION NAME] this AM d/t anxiety AEB hitting staff, throwing waste on staff and unable to redirect. Did take PO medication this AM /s (without) difficulty, but them threw water on 100 hall nurse. [MEDICATION NAME] effective at this time. ..."" - 05/08/11 at 9:30 a.m. - ""Resting in bed. Anxiety noted this AM AEB hitting, throwing cups /c water. Attempted redirection /s success, gave PRN [MEDICATION NAME] this AM. Effective at this time. ..."" - 05/08/11 at 8:00 p.m. - ""Walked into residents room to give meds. Resident sat up in bed and knocked cup of pills out of LPN's hand. ..."" - 05/09/11 at 8:00 a.m. - ""Resident has (arrow up) anxiety this AM. Removing clothes, throwing objects in room. [MEDICATION NAME] given this AM."" - 05/09/11 at 10:00 a.m. - ""[MEDICATION NAME] effective. Spoke /c Dr. (name). N/O CBC (complete blood count) / BMP (basic metabolic panel) / UA (urinalysis) C&S (culture and sensitivity) in AM. MPOA aware."" - 05/09/11 at 4:00 p.m. - ""Refused all meds @ this time attempt x 3."" - 05/10/11 at 02:30 a.m. - ""Resident combative hitting, slapping staff. Refusing straight cath. quote, ""You all are not nurses, get out, get out, I'm not letting you look at me your trash."" Unable to obtain cath for UA C &S."" Addendum: ""Resident began screaming, help help."" - 05/10/11 at 4:00 a.m. - ""Labs drawn for CBC, BMP (R) (right) AC (antecubital) By lab tech. Resident again refusing straight cath for UA C&S asked resident if go to restroom and void resident refused. ..."" - 05/10/11 at 9:00 a.m. - ""Resident refused all meds this AM ... Resident refuses to dress, wearing only robe. Attempt x 3 to cath for urine she continues to refuse."" - 05/10/11 at 11:00 a.m. - ""Staff attempting to straight cath resident /s success. She is hitting staff in face / slapping staff / kicking staff. ..."" - 05/10/11 at 5:00 p.m. - ""Refused all meds attempt x 3."" - 05/11/11 at 3:30 a.m. - ""UA obtained via straight cath method D/T (due to) behaviors."" - 05/11/11 at 8:40 p.m. - ""Resident out to (hospital) ER for direct admit to psyche unit D/T behaviors. ..."" - Review of Resident #119's care plan dated 02/24/11 found the following handwritten entries dated 05/09/11 (quoted as written): Focus: ""Behaviors of hitting, biting throwing items."" Goals: ""(Arrow down) Episodes of behaviors. Will not hurt self or others."" Interventions: ""1) MD to look at meds. 2) Offer activities appropriate for resident. 3) Labs per orders. 4) Psyche consult."" - A confidential interview with staff, in the presence of two (2) nurse surveyors on 06/28/11, revealed that, prior to her hospitalization on [DATE], Resident #119 had lived at the facility for years and had never acted like this before. No comprehensive assessment was conducted to address this significant change in Resident #119's behavior. -- 3. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found (qouted as written): - On 05/24/11 at 4:15 p.m. - ""admitted to skilled services of Dr. (name) for care ..."" - On 05/25/11 at 6:50 a.m. - ""Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid's faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roomate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident."" - On 05/25/11 at 1:50 p.m. - ""Throwing Objects @ Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up."" - 05/26/11 at 10:00 a.m. - ""Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor."" - 05/26/10 at 9:50 p.m. - ""... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out."" - 05/26/11 at 11:50 p.m. - ""Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor."" - 05/27/11 at 8:00 a.m. - ""... Has been combative /c staff since re-admit from psyche. ..."" - 05/27/11 at 10:15 a.m. - ""Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician."" - 05/28/11 at 10:00 a.m. - ""Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor."" - 05/30/11 at 9:00 a.m. - ""Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM."" - 05/30/11 at 1:00 p.m. - ""Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway."" - 05/30/11 at 1:15 p.m. - ""Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her."" - 05/30/11 at 1:30 p.m. - ""Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members."" - 05/30/11 at 4:10 p.m. - ""Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident."" - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway."" - 05/30/11 at 10:00 p.m. - ""Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor."" - 05/30/11 at 11:30 p.m. - ""Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor."" - 06/02/11 at 12:30 p.m. - ""N/O noted to send (hospital) ER for medical clearance for psych family aware."" - 06/02/11 at 1:00 p.m. - ""OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych."" -- 4. Review of the May 2011 MAR for PRN medications found the following entries: - On 05/25/11 at 1:50 p.m. - [MEDICATION NAME] was administered for ""Throwing Objects @ Roomt (roommate)"" - On 05/29/11 at 1:00 p.m. - [MEDICATION NAME] was administered for ""Throwing objects@ people, yelling, walking down hall naked"" - On 05/30/11 at 11:20 p.m. - [MEDICATION NAME] was administered for ""throwing objects at roommate, hitting staff, yelling in hallway"" -- 5. Review of Resident #119's care plan dated 05/25/11 revealed the following entries: Focus: ""Hx of Resisting treatment / care AEB refusing showers, refusing ADL's (activities of daily living), related to: Cognitive Impairment / dementia, unspecified [MEDICAL CONDITION]."" An undated handwritten addendum to this focus was ""AEB, Hitting staff throwing items."" Goals: ""Resident will comply with care routine, showers and ADLs."" Interventions: ""Administer medication for cognition as ordered. Document care being resisted on behavior monitoring flow sheet. If resident refused care, leave resident and return in 5-10 minutes. Praise / reward resident for demonstrating consistent desired / acceptable behavior."" All of these interventions were dated as having been created on 06/29/10. An undated handwritten addendum to this list of interventions was ""[MEDICATION NAME] as ordered."" Review of the aforementioned nursing notes from 04/13/11 through 05/11/11 revealed the interventions that had been in place since 06/29/10 were not effective in addressing the resident's behaviors, and no new interventions (e.g., increased staff supervision) were added - beyond the administration of [MEDICATION NAME] ""as ordered"" - to address this resident's physically / verbally abusive behaviors toward staff and other residents (including her roommate). -- c) The above information was reviewed with the administrator and director of nursing, during the late morning on 06/30/11. As of exit on 06/30/11 at 12:00 p.m., no additional information was received. .",2014-10-01
10978,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,225,D,1,0,TI3G11,". Based on medical record review, staff interview, and a review of the facility's abuse policies and procedures, the facility failed to immediately report all allegations of neglect. This occurred for one (1) of eight (8) sampled residents. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 Review of Resident #79's medical record revealed a nursing note, dated 05/28/11 at 1:30 p.m., detailing the reaction of the resident's daughter to finding the resident still in bed at lunch time. The daughter was quoted as stating, ""Why isn't she up; does she have to wait all day."" This constituted an allegation of neglect, based on the daughter's perception that care had not been provided to her mother. The daughter and her spouse then proceeded to give the resident a bed bath, changing her incontinence brief and stripping her bed without staff assistance. During an interview with the resident on 06/02/11 at 10:35 a.m., she stated, ""I told the aides I wanted to get up, and they said there wasn't enough help."" She did not remember saying she was sick and did not want to get up. She said she told her daughter when she came in to see the resident, and that was when her daughter talked to the staff. Review of the facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" found the following in the section titled ""Prevent, Procedures for Reporting Concerns, Incidents and Grievances"": ""The administrator designates a staff member as an abuse prevention coordinator to manage and evaluate the abuse prevention process. There is evidence in the center that guidelines and process to prohibit abuse, neglect, involuntary seclusion and misappropriation of property for patients are operational. The administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse. The abuse prevention coordinator interacts with the survey team to explain the center's abuse, neglect and misappropriation of patient property prevention process. ""Centers can best support the detection an prevention of abuse, neglect and misappropriation of patient property by implementing a process that supports immediate reporting of suspected abuse, neglect, neglect and misappropriation. The process should be available to patients, family members, advocates and staff to report abuse, neglect and misappropriation of patient property in a manner that elicits immediate attention without fear of retribution. The abuse prevention coordinator should provided feedback to patients, family members and staff regarding any concerns or grievances that have been exposed."" During an interview at 2:00 p.m. on 06/01/11, the director of nursing (DON), after reviewing the nursing notes for this resident, said she did not understand why the incident should have been reported to the State survey agency. .",2014-10-01
10979,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,226,D,1,0,TI3G11,". Based on medical record review, staff interview, and a review of the facility's abuse policies and procedures, the facility failed to implement its policy for reporting all allegations of neglect. This occurred for one (1) of eight (8) sampled residents. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 Review of Resident #79's medical record revealed a nursing note, dated 05/28/11 at 1:30 p.m., detailing the reaction of the resident's daughter to finding the resident still in bed at lunch time. The daughter was quoted as stating, ""Why isn't she up; does she have to wait all day."" This constituted an allegation of neglect, based on the daughter's perception that care had not been provided to her mother. The daughter and her spouse then proceeded to give the resident a bed bath, changing her incontinence brief and stripping her bed without staff assistance. During an interview with the resident on 06/02/11 at 10:35 a.m., she stated, ""I told the aides I wanted to get up, and they said there wasn't enough help."" She did not remember saying she was sick and did not want to get up. She said she told her daughter when she came in to see the resident, and that was when her daughter talked to the staff. Review of the facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" found the following in the section titled ""Prevent, Procedures for Reporting Concerns, Incidents and Grievances"": ""The administrator designates a staff member as an abuse prevention coordinator to manage and evaluate the abuse prevention process. There is evidence in the center that guidelines and process to prohibit abuse, neglect, involuntary seclusion and misappropriation of property for patients are operational. The administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse. The abuse prevention coordinator interacts with the survey team to explain the center's abuse, neglect and misappropriation of patient property prevention process. ""Centers can best support the detection an prevention of abuse, neglect and misappropriation of patient property by implementing a process that supports immediate reporting of suspected abuse, neglect, neglect and misappropriation. The process should be available to patients, family members, advocates and staff to report abuse, neglect and misappropriation of patient property in a manner that elicits immediate attention without fear of retribution. The abuse prevention coordinator should provided feedback to patients, family members and staff regarding any concerns or grievances that have been exposed."" During an interview at 2:00 p.m. on 06/01/11, the director of nursing (DON), after reviewing the nursing notes for this resident, said she did not understand why the incident should have been reported to the State survey agency. .",2014-10-01
10980,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,323,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on resident interview, medical record review, and staff interview, the facility failed to provide adequate supervision to prevent avoidable accidents for one (1) of eight (8) sampled residents. Resident #79, who was being changed by a nurse aide following an episode of incontinence, was instructed by the aide to roll over. The resident had left-sided hemiparesis as the result of a stroke as well as right sided weakness, and she was unable to use her left arm / hand to assist with bed mobility. The resident rolled out of the bed and fell to the floor, sustaining a hematoma to the left temple, resulting in evaluation and treatment at the local hospital's emergency department. Record review revealed a comprehensive minimum data set assessment (MDS) stating the resident required the assistance of two (2) or more persons with bed mobility. The occupational therapy weekly status summary stated she was dependent on staff for bed mobility. The physical therapy weekly status summary stated she required maximum assistance of two (2) with bed mobility. The care plan did not specify how many staff persons were to assist her with bed mobility, and the kardex used by the nurse aides stated she ""usually"" required the assistance of only one (1) staff person with bed mobility. There was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided hemiparesis and right-sided weakness. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 1. During a tour of the facility on 05/31/11 at 10:00 a.m., observation found Resident #79 in bed with bruising above and below her left eye. Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and oriented and possessed the capacity to understand and make informed health care decisions. Review of her nursing notes revealed an entry, on 05/15/11 at 5:00 a.m., stating (quoted as written): ""this nurse called to resident's room. CNA (certified nursing assistant) reported to this nurse that res (resident) was on the floor. upon arrival to room, res noted to be laying on (L) ( left) side between the bed & dresser. bed noted to be in low position. res stated 'My brief was being changed & suddenly the bed wasn't there.' res c/o (complained of) of left knee & ankle pain. small red raised area noted to (L) forehead / temple. res states pain is an '8' on scale of 0 -10. incontinent care provided. res assisted onto back & covered for dignity."" When interviewed on 06/01/11 at 12:45 p.m., Resident #79 reported feeling bad because her therapy was not going well as she would like. When asked, she was able to recall having fallen out of her bed on the early morning of 05/15/11. Her account was consistent with the account recorded in the nursing notes for that date. The resident reported she fell to the right. She said she had a trapeze bar but did not use it when she was being changed following incontinence episodes. -- 2. The accident / incident report, dated 05/15/11 at 5:00 a.m., stated (quoted as typed), ""during incontinent care resident rolled out of bed onto the floor landing on left side. resident is complaining of pain in the left knee and ankle. also has a knot of left forehead."" The emergency record dated 05/15/11 stated under the heading ""Instruction"": ""Discharge: Head Injury, NOS (not otherwise specified), Contusion. Follow up: Follow up with Primary Care Physician in 2-3 days. Special: Nursing home should do neurologic checks throughout the day."" -- 3. Review of Resident #79's comprehensive admission minimum data set (MDS), with an assessment reference date of 04/22/11, found in Section G the assessor encoded the resident as requiring the extensive physical assistance of two (2) or more persons with bed mobility. -- 4. Review of an occupational therapy evaluation form, signed by the occupational therapist on 04/18/11, found the following under the heading ""Summary and Assessment"": ""Res. (resident) evaluated this date for skilled OT (occupational therapy) (symbol for 'secondary') to Res & family wanting Res to return home. ... Res ... demonstrates decline /c ADL's, Fxnal (functional) mobility, (L) hand contracture at wrist PIP (proximal interphalangeal) & DIP (distal interphalangeal) jts (joints), & (L) UE (upper extremity) swelling. ..."" Review of an occupational therapy summary form, signed by the occupational therapist on 05/26/11, found the following under the heading ""Weekly Status"" related to the resident's ability to perform bed mobility: 04/18/11 - Initial Status - Dep (dependent) 04/26/11 - Dep 05/02/11 - Dep 05/10/11 - Dep 05/16/11 - Dep - Review of a physical therapy evaluation form, signed by a physical therapist on 04/16/11, found the following under the heading ""Summary and Assessment"": ""Resident presents /c (with) (L) (left) sided hemiparesis. She had CVA in 2008. ... She has had a recent decline in function and would like to resume PT (physical therapy) in attempts to improve her (R) (right) sided strength so she can assist more /c transfers and (arrow pointing) her ability for toileting / dignity."" Review of a physical therapy summary form, signed by the physical therapist on 05/19/11, found the following under the heading ""Weekly Status"" related to the resident's ability to roll / turn (bed mobility): 04/16/11 - Initial Status - Max 2 04/23/11 - NT 04/30/11 - Max 2 05/07/11 - Max 2 05/14/11 - Max - In an interview on 06/01/11 at 4:30 p.m., the rehabilitation program supervisor (Employee #80) explained that ""Max 2"" meant ""maximum assist with two (2)."" -- 5. Review of the care plan, with the director of nursing (DON) at 3:30 p.m. on 06/01/11, revealed the following: - A problem statement on page 3 of 14 (quoted as typed): ""ADL Self care deficit as evidence by need for assist with ADLs related to left [DIAGNOSES REDACTED] (Created on: 4/15/2011)."" The goal associated with this problem statement was: ""Will maintain existing ADL self performance while working with therapy services to limit further decline daily thru next review (Date initiated: 4/25/2011)."" Interventions to assist the resident in achieving this goal included: ""... Encourage and/or assist to reposition frequently (Created on 4/15/2011). ... Uses Trapeze to help assist with mobility (Created on 5/17/2011). ..."" The care plan did not specify the amount of staff assistance Resident #79 required for performing bed mobility, in view of her inability to turn on her right side independently due to left-sided hemiparesis and right-sided weakness. - - A problem statement on page 5 of 14 (quoted as typed): ""Falls due to impaired balance / poor coordination, hemiparesis related to late effects of CVA (cerebrovascular accident) (Created on 4/15/2011)."" The goal associated with this problem statement was: ""Minimize risk of injury related to falls daily through next review (Date initiated: 5/15/2011)."" Interventions to assist the resident in achieving this goal were: ""Have commonly used articles within easy reach (Date initiated: 4/15/2011). PT as ordered (Dated initiated 4/15/2011). Bariatric mattress (Dated initiated: 5/15/2011)."" The care plan, again, did not specify the amount of staff assistance Resident #79 required for performing bed mobility, especially in view of the fact that the fall occurred while the resident was being turned / repositioned to facilitate incontinence care. Additionally, the only new intervention added after the fall was to provide the resident with a bariatric mattress. -- 6. Review of the kardex found on the computer kiosk, with a nursing assistant who was providing care for the resident on 06/02/11 at 3:00 p.m. (Employee #45), found the following under the heading ""ADL's / Restorative Care"" (quoted as typed): ""*ADL Assist - Usually 1 person with total assist (encourage resident to participate as able) (FYI)"" Employee #45 reported she would sometimes reposition the resident in bed without assistance, and sometimes the resident required two (2) staff, but it just depended on how close to the edge of the bed the resident was. -- 7. Review of documentation entered by nursing assistants in the task list, regarding the amount of assistance provided to Resident #79 for bed mobility for the period 05/03/11 through 05/14/11, found the resident was repositioned by two (2) staff members on twenty-seven (27) occasions and by only one (1) staff member on eleven (11) occasions. This information was reviewed with the MDS nurse and a nurse manager (Employees #93 and #54) on the mid-afternoon of 06/01/11. -- 8. On 06/01/11 at 4:15 p.m., the administrator provide a copy of the nurse aide job description (dated 08/02 and revised 02/08) and highlighted a sentence under the heading ""Safety and Sanitation"" that stated: ""Observes safety needs of patients as indicated in care plan."" He stated Resident #79 was to receive the assistance of one (1) staff person for bed mobility. Further review of the section titled ""Personal Nursing Care Responsibilities"" found the nurse aide's responsibilities included: ""Assists resident with lifting, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc., in keeping with specific resident safety needs."" Under the heading ""Special Nursing Care Responsibilities"", one (1) of the responsibilities was: ""Turns bedfast residents as instructed."" -- 9. Because the care plan did not instruct staff in the amount of assistance to be provided for bed mobility, and because the kardex stated the resident ""usually"" required only the assistance on one (1) person for bed mobility, there was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided hemiparesis and right-sided weakness. It was determined that the resident's fall from bed on the morning of 05/15/11 was an avoidable accident. -- During an interview on the early afternoon of 06/02/11, the DON confirmed the resident was provided a bariatric bed after the fall, so she would have more room to turn. --- Part II - Based on observations and staff interview, the facility failed to provide a safe environment for residents as items not in use (such as wheelchairs, mechanical lifts, medication carts, stationary isolation cabinets, and linen carts) were stored in the hallways. This has the potential to affect residents of the facility who are independent with locomotion. Facility census: 109. Findings include: a) During a tour conducted on 05/31/11 at 10:55 a.m., the 100-200 hallways had the following equipment staged but not in use in the left side of the hallway: - Six (6) wheelchairs; - One (1) linen cart; - Two (2) white cans; - Three (3) portable vital sign machines; - One (1) cleaning cart; and - Two (2) stationary isolation carts on the left side of the hallway. Additionally, one (1) stationary isolation carts was found on the right side of the hallway. The isolation carts were observed sitting directly on the floor. They were not mobile, as they had no wheels. -- b) As the tour of the facility continued, observation found the following items staged but not in use on the 300-400 hallways: - Two (2) clean linen carts; - One (1) portable blood pressure monitor; - Three (3) stationary isolation carts; - One (1) dirty linen cart; and - One (1) wheelchair. Also observed in the hallway was a mechanical lift (staged but not in use) located just outside of an alcove where three (3) other lifts were stored. -- c) On 06/02/11 at 9:30 a.m., the administrator (Employee #133) and the maintenance director (Employee #92) were asked about the equipment staged but not in use in the 100-200 hallways. At that time, observation found: - One (1) treatment cart; - One (1) mechanical lift; - Six (6) wheelchairs; - One (1) white plastic can; - One (1) linen cart; and - One (1) geri-chair. The administrator said the building was thirty (30) years old. He also said the wheelchairs were to be collapsed and stored against the wall or in the resident's room, if space allowed. The maintenance director placed the mechanical lift in a storage alcove, and the administrator collapsed one (1) wheelchair and placed it against the wall. The other wheelchairs remained in the hallway. -- d) Further observation, on 06/02/11 at 10:55 a.m., found the same equipment in the 100-200 hallway was the same except for one (1) wheelchair (which was collapsed and stored against the wall) and the mechanical lift (which had been moved into the alcove). -- e) The administrator did not provide a policy and procedure for equipment storage, in response to the survey team's request, prior to the team's exit from the facility on the afternoon of 06/02/11. .",2014-10-01
10981,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,371,E,1,0,TI3G11,". Based on resident interview, observation, and staff interview, the facility failed to ensure dry foods were stored under sanitary conditions to prevent contamination by pests. This has the potential to affect all residents receiving food from the dietary department. Facility census: 109. Findings include: a) Residents #88 and #22 During the initial tour of the facility on 05/31/11 beginning at 9:45 a.m., two residents (#88 and #22 ) reported they did not like the Rice Crispies that was put into bowls, because they saw ""bugs"" crawling in their breakfast cereal earlier that morning. During breakfast on 06/02/11, these residents were interviewed again, and Resident #66 had two (2) bowls of Rice Crispies sitting on his overbed table. These bowls were observed, and there were no insects in the cereal at that time. In the company of the facility's dietitian (Employee #135) on 06/02/11 at 8:55 a.m., a box of bulk Rice Crispies was observed in the dry goods storage area adjacent to the kitchen. The opened box contained one (1) bag of cereal that was not opened. On the outside of the bag was a dead winged insect measuring approximately one eighth (1/8) inch in length. The insect was subsequently shown to Residents #88 and #22, and they reported this insect was similar in appearance to the ones they found in their cereal earlier in the week. The insect was then taken to the administrator for observation. An interview with the dietary manager (Employee#10), on 06/02/11 at 11:00 a.m., found the facility had a problem with inspects in the cereal about a year ago. She reported there were no other insects found in the food in dietary on 06/02/11. She said one (1) of the dietary employees prepared six (6) bowls of cereal earlier in the week, but she did not acknowledge whether there were any insects in them. .",2014-10-01
10982,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,312,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility record review, family interview, resident interview, observation, and staff interview, the facility failed to provide assistance with oral hygiene to one (1) of eight (8) sampled residents who was not independent in performing this activity. Resident identifier: #109. Facility census: 109. Findings include: a) Resident 109# Review of Resident #109's medical record revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her minimum data set assessment, with an assessment reference date of 05/11/11, indicated she had no cognitive impairment and she required the extensive assistance of staff for personal hygiene including brushing teeth. A care plan, initiated by the resident assessment coordinator (Employee #102) on 05/03/11, contained the following intervention: ""Assist with daily hygiene, grooming, dressing, oral care and eating as needed."" In an interview on 06/01/2011 at 9:30 a.m., Resident #109's family member said she had complained that her mouth was sore approximately ten (10) days after her admission to the facility. The family member inspected the resident's mouth and stated, ""It made me sick."" Mouth care products brought to the facility by the family on admission had not been used. On 06/01/11 at 4:30 p.m., an interview with Resident #109 revealed no oral or denture care had been provided. When asked if her dentures had been cleaned today, she replied, ""No."" When asked how many times, over the last five (5) days, staffed cleaned her dentures, she stated ""twice"". Her dentures were observed to contain food particles. During this interview, the resident repeatedly put her hand over her mouth. On 06/02/11 at 10:00 a.m., the director of nursing (DON - Employee #18) was asked for a copy of the activity of daily living (ADL) documentation for Resident #109, on which direct care staff were to record the provision of ADL assistance given to the resident. The ADL sheet did not contain any documentation of oral care. The DON said mouth care was not recorded and was considered part of the ADLs that were to be completed by direct care staff. .",2014-10-01
10983,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,242,B,1,0,TI3G11,". Based on confidential resident interviews, review of the facility's planned cycle menus, observation, and staff interview, the facility failed to afford residents the right to choose a meal plan containing a variety of food items. The planned cycle menus for Weeks #1 and #3 were repetitious of entrees comprised of meat / tomato products and fish with breading and tartar sauce, respectively. Facility census: 109. Findings include: a) In confidential interviews, residents complained of the food items on the menu being ""all the same"", with little variety at times. Observation of the facility's current 4-week cycle menu found, in Week #1, three (3) consecutive days when the entrees included meat and tomato products in combination. On Tuesday 05/31/11 at the noon meal, the entree was Coney Chili on Bun; this was tasted by two (2) surveyors. On Wednesday 06/01/11 at the evening meal, the entree was Sloppy Joe on Bun; this was also sampled by the surveyors and was found to be very similar in taste, appearance, and texture to the Coney Chili offered the previous day at lunch. A review of the cycle menu and the recipes for both Coney Chili and Sloppy Joes, with the dietary manager (Employee #10) on the evening of 06/01/11, found the contents, flavor, and appearance of both items were similar. Further review of the menu with the dietary manager found a third meat / tomato product entree was to be served at the noon meal on Wednesday 06/02/11 - BBQ Pork on Bun. All three (3) of these items were found on the planned cycle menu for Week #1. Further review of the same cycle menu found, for Week #3, the following three (3) entrees that would be similar in content, taste, and appearance: - Sunday evening meal - Fish Sandwich with Tartar Sauce - Tuesday evening meal - Breaded Fish with Tartar Sauce - Wednesday noon meal - Crumb Topped Fish with Tartar Sauce The dietary manager acknowledged the menu did appear to include entrees that were similar to each other, and she agreed the taste and appearance of these entrees would be similar in nature. .",2014-10-01
10984,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,279,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on a comprehensive assessment to prevent avoidable accidents for one (1) of eight (8) sampled residents. Resident #79, who was being changed by a nurse aide following an episode of incontinence, was instructed by the aide to roll over. The resident had left-sided [MEDICAL CONDITION] as the result of a stroke as well as right sided weakness, and she was unable to use her left arm / hand to assist with bed mobility. The resident rolled out of the bed and fell to the floor, sustaining a hematoma to the left temple, resulting in evaluation and treatment at the local hospital's emergency department. Record review revealed a comprehensive minimum data set assessment (MDS) stating the resident required the assistance of two (2) or more persons with bed mobility. The occupational therapy weekly status summary stated she was dependent on staff for bed mobility. The physical therapy weekly status summary stated she required maximum assistance of two (2) with bed mobility. The care plan did not specify how many staff persons were to assist her with bed mobility, and the kardex used by the nurse aides stated she ""usually"" required the assistance of only one (1) staff person with bed mobility. There was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided [MEDICAL CONDITION] and right-sided weakness. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 1. During a tour of the facility on 05/31/11 at 10:00 a.m., observation found Resident #79 in bed with bruising above and below her left eye. Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and oriented and possessed the capacity to understand and make informed health care decisions. Review of her nursing notes revealed an entry, on 05/15/11 at 5:00 a.m., stating (quoted as written): ""this nurse called to resident's room. CNA (certified nursing assistant) reported to this nurse that res (resident) was on the floor. upon arrival to room, res noted to be laying on (L) ( left) side between the bed & dresser. bed noted to be in low position. res stated 'My brief was being changed & suddenly the bed wasn't there.' res c/o (complained of) of left knee & ankle pain. small red raised area noted to (L) forehead / temple. res states pain is an '8' on scale of 0 -10. incontinent care provided. res assisted onto back & covered for dignity."" When interviewed on 06/01/11 at 12:45 p.m., Resident #79 reported feeling bad because her therapy was not going well as she would like. When asked, she was able to recall having fallen out of her bed on the early morning of 05/15/11. Her account was consistent with the account recorded in the nursing notes for that date. The resident reported she fell to the right. She said she had a trapeze bar but did not use it when she was being changed following incontinence episodes. -- 2. The accident / incident report, dated 05/15/11 at 5:00 a.m., stated (quoted as typed), ""during incontinent care resident rolled out of bed onto the floor landing on left side. resident is complaining of pain in the left knee and ankle. also has a knot of left forehead."" The emergency record dated 05/15/11 stated under the heading ""Instruction"": ""Discharge: Head Injury, NOS (not otherwise specified), Contusion. Follow up: Follow up with Primary Care Physician in 2-3 days. Special: Nursing home should do neurologic checks throughout the day."" -- 3. Review of Resident #79's comprehensive admission minimum data set (MDS), with an assessment reference date of 04/22/11, found in Section G the assessor encoded the resident as requiring the extensive physical assistance of two (2) or more persons with bed mobility. -- 4. Review of an occupational therapy evaluation form, signed by the occupational therapist on 04/18/11, found the following under the heading ""Summary and Assessment"": ""Res. (resident) evaluated this date for skilled OT (occupational therapy) (symbol for 'secondary') to Res & family wanting Res to return home. ... Res ... demonstrates decline /c ADL's, Fxnal (functional) mobility, (L) hand contracture at wrist PIP (proximal interphalangeal) & DIP (distal interphalangeal) jts (joints), & (L) UE (upper extremity) swelling. ..."" Review of an occupational therapy summary form, signed by the occupational therapist on 05/26/11, found the following under the heading ""Weekly Status"" related to the resident's ability to perform bed mobility: 04/18/11 - Initial Status - Dep (dependent) 04/26/11 - Dep 05/02/11 - Dep 05/10/11 - Dep 05/16/11 - Dep - Review of a physical therapy evaluation form, signed by a physical therapist on 04/16/11, found the following under the heading ""Summary and Assessment"": ""Resident presents /c (with) (L) (left) sided [MEDICAL CONDITION]. She [MEDICAL CONDITION] 2008. ... She has had a recent decline in function and would like to resume PT (physical therapy) in attempts to improve her (R) (right) sided strength so she can assist more /c transfers and (arrow pointing) her ability for toileting / dignity."" Review of a physical therapy summary form, signed by the physical therapist on 05/19/11, found the following under the heading ""Weekly Status"" related to the resident's ability to roll / turn (bed mobility): 04/16/11 - Initial Status - Max 2 04/23/11 - NT 04/30/11 - Max 2 05/07/11 - Max 2 05/14/11 - Max - In an interview on 06/01/11 at 4:30 p.m., the rehabilitation program supervisor (Employee #80) explained that ""Max 2"" meant ""maximum assist with two (2)."" -- 5. Review of the care plan, with the director of nursing (DON) at 3:30 p.m. on 06/01/11, revealed the following: - A problem statement on page 3 of 14 (quoted as typed): ""ADL Self care deficit as evidence by need for assist with ADLs related to left [MEDICAL CONDITION] (Created on: 4/15/2011)."" The goal associated with this problem statement was: ""Will maintain existing ADL self performance while working with therapy services to limit further decline daily thru next review (Date initiated: 4/25/2011)."" Interventions to assist the resident in achieving this goal included: ""... Encourage and/or assist to reposition frequently (Created on 4/15/2011). ... Uses Trapeze to help assist with mobility (Created on 5/17/2011). ..."" The care plan did not specify the amount of staff assistance Resident #79 required for performing bed mobility, in view of her inability to turn on her right side independently due to left-sided [MEDICAL CONDITION] and right-sided weakness. - - A problem statement on page 5 of 14 (quoted as typed): ""Falls due to impaired balance / poor coordination, [MEDICAL CONDITION] related to late effects [MEDICAL CONDITION] (Created on 4/15/2011)."" The goal associated with this problem statement was: ""Minimize risk of injury related to falls daily through next review (Date initiated: 5/15/2011)."" Interventions to assist the resident in achieving this goal were: ""Have commonly used articles within easy reach (Date initiated: 4/15/2011). PT as ordered (Dated initiated 4/15/2011). Bariatric mattress (Dated initiated: 5/15/2011)."" The care plan, again, did not specify the amount of staff assistance Resident #79 required for performing bed mobility, especially in view of the fact that the fall occurred while the resident was being turned / repositioned to facilitate incontinence care. Additionally, the only new intervention added after the fall was to provide the resident with a bariatric mattress. -- 6. Review of the kardex found on the computer kiosk, with a nursing assistant who was providing care for the resident on 06/02/11 at 3:00 p.m. (Employee #45), found the following under the heading ""ADL's / Restorative Care"" (quoted as typed): ""*ADL Assist - Usually 1 person with total assist (encourage resident to participate as able) (FYI)"" Employee #45 reported she would sometimes reposition the resident in bed without assistance, and sometimes the resident required two (2) staff, but it just depended on how close to the edge of the bed the resident was. -- 7. Review of documentation entered by nursing assistants in the task list, regarding the amount of assistance provided to Resident #79 for bed mobility for the period 05/03/11 through 05/14/11, found the resident was repositioned by two (2) staff members on twenty-seven (27) occasions and by only one (1) staff member on eleven (11) occasions. This information was reviewed with the MDS nurse and a nurse manager (Employees #93 and #54) on the mid-afternoon of 06/01/11. -- 8. On 06/01/11 at 4:15 p.m., the administrator provide a copy of the nurse aide job description (dated 08/02 and revised 02/08) and highlighted a sentence under the heading ""Safety and Sanitation"" that stated: ""Observes safety needs of patients as indicated in care plan."" He stated Resident #79 was to receive the assistance of one (1) staff person for bed mobility. Further review of the section titled ""Personal Nursing Care Responsibilities"" found the nurse aide's responsibilities included: ""Assists resident with lifting, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc., in keeping with specific resident safety needs."" Under the heading ""Special Nursing Care Responsibilities"", one (1) of the responsibilities was: ""Turns bedfast residents as instructed."" -- 9. Because the care plan did not instruct staff in the amount of assistance to be provided for bed mobility, and because the kardex stated the resident ""usually"" required only the assistance on one (1) person for bed mobility, there was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided [MEDICAL CONDITION] and right-sided weakness. It was determined that the resident's fall from bed on the morning of 05/15/11 was an avoidable accident. (See also citation at F323.) -- During an interview on the early afternoon of 06/02/11, the DON confirmed the resident was provided a bariatric bed after the fall, so she would have more room to turn. .",2014-10-01
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
10989,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-06-30,279,D,1,0,106Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, observation, record review, and staff interview, the facility failed to provide interventions detailing how staff would address the resident's behavior problems related to cognitive deficits, which occurred during meal times. This was true for one (1) of three (3) sampled residents who had the potential for weight loss. Resident identifier: #15. Facility census: 58. Findings include: a) Resident #15 During interviews with Residents #1, #21, and #37 on 06/28/11, concerns were voiced regarding Resident #15's behavior while eating meals in the dining room. Resident #21 stated, ""You can't eat in there. The noise is like eating in a road house."" The residents stated Resident #15 was very loud, constantly yelling, and they all stated she roamed around the dining room taking food off other residents' trays, Observation of the noon meal on 06/29/11 found Resident #15 was removed from her wheelchair and seated at a table in the dining room for her meal. The resident clapped her hands, talked very loudly in irrelevant conversation, and banged her spoon on her plate during the entire meal. She only consumed a small portion of her meal. Review of the dietary progress notes dated 06/15/11 revealed, ""... She eats most meals in the dining room or the quiet lounge. ... She feeds herself with tray setup help."" A dietary progress note for 03/09/11 revealed, ""She will eat most meals in the dining room unless she yells and screams at other residents."" review of the resident's medical record revealed [REDACTED]. On 01/06/11, the resident's weight was 161 pounds. On 06/15/11, the resident's weight was 153 pounds. Review of the resident's care plan, updated on 06/15/11, revealed the following problem statement: ""Potential for wt. (weight) loss due to cognitive deficits affecting her ability to feed self, mechanically altered diet,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), [MEDICAL CONDITION], constipation, [MEDICAL CONDITION] and diuretic use. Has short attention span. Daughter wants resident OOB (out of bed) for meals."" The resident's goal for this problem was: ""Resident will maintain wt +/- 5 #(weight plus or minus five pounds) thru next review."" The interventions for obtaining this goal were: ""Labs as ordered for diuretic care given, obtain wt. per facility policy, diet as ordered per physician, medicate for GERD, offer alternate choices at meals, snacks to maintain wt. per order and 2% milk with meals, daughter requests soda on lunch / dinner tray."" The care plan did not specify where the resident would eat her meals, what actions the staff could provide for re-direction if behaviors occurred, how much assistance staff should provide during meals, and how to address the resident's short attention span. The director of nursing, when interviewed on the morning of 06/30/11, verified the resident was easily distracted and reported that a care plan would be written to address the resident's behaviors. She verified the resident would roam around the dining room if not removed from her wheelchair. .",2014-10-01
10990,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-06-30,364,F,1,0,106Q11,". Based on observation, review of facility policy, and staff interview, the facility failed follow their own policy to obtain and record food temperatures prior to meal service, to ensure foods were held and served at the proper temperature. This deficient practice had the potential to affect all residents who receive meals from the kitchen. Facility census: 58. Findings include: a) As a result of a complaint from a family member alleging hot meals were served cold, the kitchen was entered at 9:15 a.m. on 06/29/11 to obtain a copy of the food temperature log. Observation revealed all meals being served to residents had left the kitchen. Employee #1, the dietary manager, presented the food temperature log. The food temperatures for the breakfast meal on 06/29/11 had not been completed. Employee #4, the cook, stated she had taken the temperatures and had written them down but had not had time to copy them onto the log. Employee #4 continued to clean the kitchen. After requesting the temperatures, Employee #4 picked up the log and began writing the temperatures of the food items served for breakfast which included the temperature of the, ""Eggs, hot cereal and pureed hot item."" Employee #4 did not reference any prior written copy of the food temperatures. She stated, ""I can remember the temperatures."" Employee #4 did not record the temperature of the cold food items, milk and juice, that were served for this meal. Further review of the food temperature log revealed temperatures had not been taken for the cold food items served on 06/27/11 or 06/28/11. The food temperature log also failed to contain the temperature of the bacon and sausage that was also served for the morning meal on 06/29/11. Employee #1 verified the temperatures of all food items were to be taken prior to service and recorded on the temperature log before service begins. He verified this was how the facility ensured foods were served at the proper temperature. Review of the facility's policy titled ""Food Temperature"" revealed: ""... a recording form is also needed to document temperatures. ..."" and temperatures are to be obtained ""prior to serving"".",2014-10-01
10991,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,371,F,0,1,9CS011,". Based on observation and staff interview, the facility failed to store foods in a manner that maintained sanitary conditions. Food items located in the walk-in refrigerator did not have labels or dates, open items on shelves had no dates on the container, food items were left on the steam table for an extended period of time, and the drip pans of the oven were in need of cleaning. These issues had the potential to affect all residents who consume foods by oral means, as all food comes from this central location. Facility census: 50. Findings include: a) While on the initial tour with the dietary manager (Employee #18) on the afternoon of 07/12/10, the following issues were found: In the walk-in refrigerator were two (2) plastic containers of what was identified as red peppers with no label. Also observed was an open package of cheese slices with a date of ""7/5/10"". Employee #18 stated the facility policy was to keep open items no longer than three (3) days. The opened package of cheese slices had been stored for seven (7) days, which was longer than allowed by facility policy. On a storage rack near the food preparation area, a container of spice was open, and the bottom of the container was wrapped in Saran wrap. When questioned, the dietary staff said the bottom of the container was busted, and that was why it was wrapped. There was no date on the item to track how long it had been open. b) The drip pan under the range top contained a build-up food debris and was in need of cleaning. Additionally, items were noted to be on the steam table at 1:45 p.m. (mashed potatoes and beef). If these items had been from lunch, they were not immediately refrigerated after service to prevent any food deterioration. c) On 07/19/10, a tour of the environment revealed the facility had not assured the sandwiches (residents' snacks) stored in the small refrigerator located behind the facility's only nursing station were dated and labeled. When asked, a nurse (Employee #29) reported the night shift nurses were supposed to discard these sandwiches at the end of their shift. The staff had no way to determine how long these sandwiches were placed in the small refrigerator, nor was there any way to determine what type of sandwiches were in the bags without opening the bags and touching them. .",2014-10-01
10992,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,253,E,0,1,9CS011,". Based on observation and staff interview, the facility failed to maintain a sanitary and/or aesthetic interior in which the residents reside. This was evident by the condition of the common bathing areas for both A and B wings, scuffed entry doors for most of the B Hall rooms and for many of the A Hall rooms, heating / cooling units with dirt and/or dust balls in both A Hall and B Hall rooms, strips of molding were loose or missing in three (3) rooms on the B Hall, furniture marred or in poor conditions in several rooms on the A Hall, and one (1) room on the A Hall with peeling paint. Overall, sixteen (16) of seventeen (17) rooms on the B Hall and nine (9) of sixteen (16) rooms on the A Hall had issues. Number of resident rooms in the facility: 33. Facility census: 50. Findings include: a) Shower rooms 1. Observation of the A Hall shower room, during the initial tour of the facility on 07/12/10 beginning shortly after 1:00 p.m., found the inside of the wooden door was scuffed. Paint was peeling on the door frame and on the baseboard. The floor looked as if it needed to either be painted or scrubbed due to numerous black splotches on the white floor that could not be wiped off with a towel. The edging around the tile as it meets the floor needed to be sealed with caulk. Chipped paint was present on the floor of the shower stall. 2. Observation of the B Hall shower room, during the initial tour of the facility on 07/12/10 beginning shortly after 1:00 p.m., found the room had chunks of broken tile on the baseboards and on the shower floor. The floor looked as if it needed to either be painted or scrubbed due to numerous black splotches on the white floor that could not be wiped off with a towel. The wooden entrance door was scratched. 3. During interview with the maintenance / housekeeping supervisor on 07/19/10 at 4:00 p.m., he said he discussed the shower room with the life safety code surveyor, and the facility had plans to do a treatment on the floors in the shower room such as the hospital. During interview with the administrator on 07/21/10 at approximately 9:00 a.m., she spoke of her awareness of the plan to resurface the shower room floor soon. b) B Hall 1. Observation of the heating / air conditioning units on the B Hall, on 07/19/10, revealed dirty control panels and/or dirty grated panels with dust thick enough to be wiped off with a finger. Those rooms were: B18, B20, B22, B23, B24, B25, B26, B27, B28, B29, B30, B31, B32, and B33. During interview with the maintenance / housekeeping supervisor on 07/19/10 at 4:00 p.m., he said he would see that all the heating / cooling units in the B Hall were cleaned and taken care of, and he indicated this was, in part, due to a recent change in staff. 2. Observation of the resident room doors on the B Hall, on 07/19/10, found that most of the doors had some scuffing in the varnish, some worse than others and with small chips knocked off the wood. Those rooms with moderate scuffing included: B18, B19, B20, B22, B23, B25, B26, B27, B29, B30, B31, and B33. During interview with the maintenance / housekeeping supervisor on 07/19/10 at 4:00 p.m., he acknowledged the doors have gotten scratched and nicked due mainly to the portable scales being brought into the rooms and to wheelchairs hitting into them. He said the only way to fix them would be to take them off, sand them, and revarnish them. During interview with the administrator on 07/21/10 at approximately 9:00 a.m., she said the facility would not have enough cash flow to replace the doors and preferred to spend money on the actual care of residents. 3. Observation of the resident rooms on the B Hall, on 07/19/10, found three (3) rooms had loose or missing strips of molding. Those rooms were: B31 with loose molding between the beds; B28 with loose molding close to the bed; and a missing strip of molding behind the first bed in B35. During interview with the maintenance / housekeeping supervisor on 07/19/10 at 4:00 p.m., he said he was aware of the strips of molding in the B Hall needing repair. He said the maintenance department was made aware of the strips of molding in two (2) of those rooms, based on staff reports. He said staff is supposed to make out work orders or repair requests anytime they see anything that needs attention. c) During a tour of the facility's A hall on 07/19/10 at approximately 11:30 a.m., observations revealed environmental issues that did not make the facility appear homelike. The doors on the outside of the following rooms had scratches, scuff marks near the bottom and tape marks in the middle and closer to the top: A17, A16, and A10. The air conditioning / heating units in rooms A9, A10, A 14, A12, A15, and A16 were dirty. The units were enclosed in a metal compartment. The outside of the compartment had crevices that were filled with dust and debris. The nightstands in rooms A14 and A9 were scuffed and had places where the finishing had worn off, making the surfaces uncleanable. In room A16, the paint behind the bed showed signs of peeling, and the wall had scratches behind the bed. The extra chair provided by the facility in room A6 had scratches on the legs, and the television stands also provided by the facility had scratches in rooms A5 and A9. At approximately 12:00 p.m., the administrator agreed the facility needed to place a board behind the recliner chair in room A16. She felt the marks on the wall were a result of the resident's recliner chair hitting the wall. Some rooms did have a board placed behind the recliners, and this had seemed to prevent the wall from being scratched. The administrator also indicated the facility had thought about getting guards to go on the doors to prevent wheelchairs and other equipment from rolling into them and scratching them. The additional issues were also pointed out to the administrator, and she agreed they needed to be corrected. .",2014-10-01
10993,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,309,D,0,1,9CS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to provide medications as prescribed by the physician for two (2) of twenty-four (24) Stage II sample residents. This deficient practice had the potential to cause symptoms such as dry mouth, hoarseness, or irritated throat for one (1) resident who received the wrong dose of inhaled corticosteroid and who also was not given an opportunity to rinse his mouth after use of the inhaler, and had the potential to cause gastric upset or ulcer in another resident who was ordered but did not receive an [MEDICATION NAME] coated medication daily. Also, the facility failed to assess a resident's skin tear as prescribed by the physician for one (1) of twenty-four (24) Stage II sample residents, which had the potential to to compromise wound healing. Resident identifiers: #30, #7, and #4. Facility census: 50. Findings include: a) Resident #30 During observation of a medication pass on 07/12/10 at 4:40 p.m., the nurse (Employee #59) administered two (2) puffs of Q-VAR inhaler, a corticosteroid used to prevent or reduce the seriousness of asthma attacks. The nurse had this resident exhale fully, then breathe in one (1) puff, waiting less than ten (10) seconds to administer a second inhalation. Review of the physician's orders [REDACTED].#30 received. Also, it was recommended by the manufacturer to rinse the mouth or gargle with water after using this medicine to prevent mouth sores or bad taste, but this was not done. Also, if per chance the medication would be prescribed for two (2) puffs, several minutes should have elapsed between the two (2) doses. During reconciliation of the physician's orders [REDACTED].#59 acknowledged the error made during the medication pass - b) Resident #7 During observation of a medication pass on 07/13/10 at 9:08 a.m., the nurse (Employee #28) obtained an Aspirin 81 mg chewable tablet from Resident #7's drawer in the medication cart, placed the tablet whole in some vanilla Magic Cup along with [MEDICATION NAME] for hypertension, and gave it to Resident #7 on a spoon. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. On 07/15/10 at 10:44 a.m., Employee #59 checked Resident #7's medication drawer on the medication cart and found it contained children's chewable aspirin 81 mg. When asked if they were allowed to substitute chewable aspirin for [MEDICATION NAME]-coated aspirin, she said she did not know. During interview with Resident #7 on 07/15/10 at 11:05 a.m., he denied abdominal discomfort, reported he can and does swallow whole pills, and expressed that he would prefer to have [MEDICATION NAME]-coated aspirin rather than children's chewable aspirin. During a telephone interview with a pharmacy director on 07/15/10 at 11:17 a.m., he said Resident #7's [MEDICATION NAME]-coated aspirin was discontinued on 11/16/08 and the resident had been receiving chewable aspirin since then. During interview on 07/15/10 at 11:40 p.m., a nurse (Employee #63) stated her belief that, since the MAR gave 07/28/05 as the inception date for the daily [MEDICATION NAME]-coated aspirin, the pharmacy should have been sending that medication instead of chewable. Subsequently, she said she would look into the matter and correct it. - c) The director of nursing offered no further information around noon on 07/15/10, when these findings for Residents #30 and #7 were discussed. - d) Resident #4 During the facility initial tour on 06/19/10 at approximately 2:00 p.m., observation of Resident #4's right arm revealed a small circular red area. On 06/25/10 at approximately 1:00 p.m., the medical record review for Resident #4 revealed a physician order [REDACTED]."" A review of the skin assessment sheets did not reveal any documentation pertaining to area on the resident's right forearm. There were measurements recorded for an area on the left forearm but none for the right forearm. On 07/15/10 at approximately 1:00 p.m., Employee #63 (a licensed practical nurse) indicated she had discontinued the physician's orders [REDACTED]. She indicated she had confused this with the order to discontinue the measurement and recording of the skin condition on the resident's left forearm. The treatment record reflected both orders for measurement to both the left and right forearm were discontinued on 07/08/10. Employee #63 agreed she had inadvertently discontinued the order for checking and measuring the area on the resident's right forearm on 07/08/10, when there were no orders for the discontinuation of this treatment. The medical record did contain a physician order [REDACTED]. .",2014-10-01
10994,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,280,D,0,1,9CS011,"**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-four (24) Stage II sample residents. Although a resident was prescribed a hypnotic medication nightly, there were no goals or interventions on the care plan which addressed the possible side effects to watch for, nor did the care plan contain any non-pharmacologic interventions to promote sleep for a resident diagnosed with [REDACTED].#7. Facility census: 50. Findings include: a) Resident #7 Record review found the care plan was not revised to include possible side effects, risks and benefits related to hypnotic medication ([MEDICATION NAME]) this resident received daily. The care plan also lacked non-pharmacologic interventions to promote good sleep hygiene for this resident with a [DIAGNOSES REDACTED]. During interview on 07/14/10 at 3:33 p.m., the nurse (Employee #61) said Resident #7 was always alert and bright and had shown no negative side effects from the drug or extrapyramidal symptoms. When asked, she said the potential side effects of [MEDICAL CONDITION] medications were listed on the care plan and were not written on the Medication Administration Record [REDACTED] During interview with another nurse (Employee #63) on 07/19/10, she said the potential side effects of this drug and the goals of not experiencing any negative side effects related to hypnotic medication use should have been on page 2 of the resident's care plan listed under goals and interventions, but it was not. She added that all the residents on [MEDICAL CONDITION] medications should have this information on their care plan, and she did not know why his was missed. The director of nursing offered no further information around noon on 07/15/10, when these findings were discussed. .",2014-10-01
10995,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,176,D,0,1,9CS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and record review, the facility failed to assure residents who are assessed as being unable to self-administer their own medications are not allowed to do so. This was evident for one (1) of ten (10) sampled residents, wherein the nurse failed to complete the medication administration process when she left the resident's medication at the bedside for him to take without her oversight. Resident identifier: #45. Facility census: 50. Findings include: a) Resident #45 Observation of a medication pass, on 07/12/10 at 4:29 p.m., revealed the nurse (Employee #59) administered Resident #45's insulin, gave him water with which to take three (3) medications / tablets, then turned and left the room without witnessing him take the oral medications. After completion of all the medication passes, this observation was shared with the nurse, and she acknowledged she should have stayed with him until he took his medications. Review of the medical record revealed physician's orders [REDACTED]. The director of nursing was informed of the above findings at about 12:00 p.m. on 07/15/10, and she presented no further information. .",2014-10-01
10996,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,431,E,0,1,9CS011,". Based on observation, staff interview, and policy review, the facility failed to follow its own policy to maintain locked medication carts in the hallways when unattended. Medication carts were found unlocked on the B Hall on three (3) separate occasions and on two (2) shifts. This had the potential to affect any wandering residents, visitors, and staff on the B Hall. Facility census: 50. Findings include: a) Observation of the B Hall medication pass, on 07/13/10 at 9:15 a.m., found while the nurse (Employee #28) administered medications to Resident #37, the back of the medication cart facing the hallway was left unlocked; also, one (1) of the individual drawers of medication on the back of the cart was pushed out. Employee #28 was giving medications to Resident #37 and was not able to view the back of the medication cart from within the room; she also had her back turned away from the cart while giving the resident her medications. When asked, Employee #28 said both sides of the cart will lock if one pushes both locks, one (1) on each side, and she demonstrated the cart could be locked on both sides. She said she could see the cart from the room. b) Random observation, on 07/19/10 at 3:50 p.m., found the B Hall medication cart parked in the hallway unlocked. The back of the cart contained drawers with medications for residents, any of which could be pulled out and drugs accessed by anyone passing by the back of the cart. The nurse (Employee #69) was giving medications in room B20 and was not able to view the back of the medication cart from within the room. When asked, Employee #64 said she thought she had locked the cart, and generally, both the front and back of the cart lock when she engages the lock. She demonstrated that both sides can be locked. c) Random observation, on 07/21/10 at 9:28 a.m., found the B Hall medication cart parked in the hallway unlocked. The back of the cart contained drawers with medications for residents, any of which could be pulled out and drugs accessed by anyone passing by the back of the cart, and was unlocked. Employee #29 was giving medications to Resident #37 and was not able to view the back of the medication cart from within the room; she also had her back turned away from the cart while giving the resident her medications. When asked, she said she did not think she had to lock the cart if she was right in the room and in sight of the cart. d) Review of the policy and procedure titled ""Admittance To Medication Room"" the following: ""Medication carts will not be left in hallways unlocked when unattended."" e) The director of nursing was informed of the above findings prior to exit on 07/21/10, and no further information was presented.",2014-10-01
10997,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,223,G,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to ensure residents were free from abuse. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others (beyond Resident #12), and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and ""X"". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and ""X"" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - ""Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone."" (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - ""Employee was alleged to have squirted water on resident (#62). ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee tied resident's (#30) wheelchair to side rail. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#61) to yell and cuss. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that this employee placed cold water on the resident's face (#62). ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee was verbally inappropriate to residents."" (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee put resident (#60) to bed in a rough manner. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #30)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #12)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds."" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..."" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..."" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)"" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them."" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/23/10 by Employee #79 (a CNA): ""I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- 3. Failure to Meet Reporting Requirements Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their ""scope of practice"", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident ""X"" to keep them from falling -- Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - A review of Resident #12's medical record revealed she have a [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. The director of nursing and the registered nurse consultant, when interviewed on the afternoon of 06/09/11, agreed the medical record contained no documentation regarding why Employee #81 digitally removed stool from Resident #12. - Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. (See also citation at F225.) - Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected three (3) residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09). (See also citations at F225 and F226.) .",2014-10-01
10998,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,225,E,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations and draw the appropriate conclusions based on the information available to them; and (4) report to all State agencies those individuals who had knowledge of the abuse / neglect by Employee #81 and both failed to intervene to protect the residents from further abuse / neglect and failed to fulfill their roles as mandatory reporters. Eleven (11) employees had knowledge of mistreatment / abuse / neglect occurring to residents in the facility and did not report this to their supervisor, to their administrator, or to any outside agency responsible for receiving reports of abuse / neglect in nursing homes. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when the events were witnessed by two (2) other staff members, and no reasons for making these determinations were documented. After receiving statements from eleven (11) employees revealing they had knowledge of resident abuse / neglect by Employee #81, the facility did not report these individuals for failing to protect the residents from further abuse / neglect and for failing to fulfill their roles as mandatory reporters. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and an unidentified resident who was no longer at the facility (""X""). Employee identifiers: #5, #50, #51, #35, #58, #59, #67, #71, #72, #73, #74, #75, #79, #80, and #81. Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and ""X"" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - ""Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone."" (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - ""Employee was alleged to have squirted water on resident (#62). ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee tied resident's (#30) wheelchair to side rail. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#61) to yell and cuss. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that this employee placed cold water on the resident's face (#62). ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee was verbally inappropriate to residents."" (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee put resident (#60) to bed in a rough manner. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #30)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #12)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds."" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..."" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..."" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)"" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them."" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/23/10 by Employee #79 (a CNA): ""I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- 3. Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their ""scope of practice"", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident ""X"" to keep them from falling -- 4. Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. -- 5. After reviewing witness statements collected from employees by the facility, it was unclear why some of the allegations were not substantiated by the facility: - Employees #74, #73, #50, #79, and #51 reported witnessing (or participating in) nursing assistants performing duties for which they were not trained, including invasive procedures (i.e., fingersticks and insulin injections). The facility did not report or investigate these allegations. - Employees #74, #67, and #51 reported having witnessed Employee #81 throw water, shoot water or saline with a syringe, or spray water on residents. The facility did not substantiate these allegations. - Employees #73 and #74 both reported having witnessed Employee #81 slamming residents' doors and yelling at residents at night when residents were sleeping. The facility did not report or investigate this allegation. - Employees #51 and #73 both reported having witnessed Employee #81 holding Resident #12's nose and/or mouth closed in order to get the resident to swallow medications, food and/or fluids. The facility did not investigate or substantiate this allegation. - Employee #74 reported having witnessed Employee #81 hold residents' noses closed and pry open their mouths to give them medications. The facility did not question Employee #74 to determine the name(s) of the resident(s) she observed. - Employee #73 reported having witnessed Employee #81 record her initials in residents' records to indicate she administered medications to them, but she did not give the residents these medications. The facility did not question Employee #73 as to which residents were affected. - Employee #67 reported having witnessed Employee #81 tie garbage bags around Resident #12 and Resident X to keep them from falling. The facility did not report or investigate allegations of involuntary seclusion involving Resident X (whose first name only was provided in Employee #67's written statement). - The executive director (administrator), when interviewed on the afternoon of 06/09/11, had no further information related to the investigations. She stated she had completed the investigations with the assistance of Employee #35 (social services supervisor) and felt they were thorough and complete at the time. -- 6. The facility's titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09) stated, on Pages 2 and 3: ""- Training will be provided to all employees, through orientation and ongoing sessions, (upon hire and at least annually) and will include but not be limited to the following: 1. the AMFM, Inc. abuse, neglect, involuntary seclusion, and misappropriation of property prohibition policy; 2. what constitutes abuse, neglect, and misappropriation of resident property; 3. how staff should report their knowledge related to allegations without fear of reprisal; 4. appropriate interventions to address and or deal with aggressive and/or inappropriate reactions of residents; 5. how to recognize signs of frustration and stress that lead to abuse; and 6. the statutory requirement of all employees to report abuse and neglect of a resident. "" ""- Prevention of abuse, neglect, involuntary seclusion, and misappropriation of property shall include but not be limited to the following: 1. Educating residents, families and staff with information on the reporting process of allegations, concerns, incidents, and grievances. This education shall also include the knowledge that communicating any of the above will not result in reprisal or any form of retribution. Staff will also provide feedback and/or follow up regarding concerns that have been expressed. 2. The staff shall also be educated in identifying, correcting and intervening in situations in which abuse, neglect and/or misappropriation of customer property may be more likely to occur. ... ""... 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 then to immediately report it to his/her immediate supervisor. ""... The family / responsible party and attending physician shall be notified and recommendation(s) shall be followed. Documentation of notifications, recommendations and actions taken shall be documented as part of the investigation. ..."" Beginning on Page 4 of the policy and procedures, under the heading ""D. Investigation"", was found: ""Upon receiving information regarding an allegation of abuse or neglect the Executive Director or designee shall: ""Immediately refer to the Step One: Decision Tree for Determining the Reportability of an Incident or Allegation and Step Two: Internal and External Notification of A Reportable Incident or Allegation (see Tables 1 and 2) to assure notification if the event is reportable and initiate an investigation. ""Report the allegation(s) to the appropriate state agencies within the required time frames (see Tables 3 and 4). ""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: 1. determine if the alleged abuse or neglect occurred and to what extent, 2. clinical examination for signs of injuries, if indicated, 3. a review of AMFM, Inc. policies that are related to the incident, 4. causative factors, trends, 5. determine the root cause of the incident, 6. identify interventions to prevent further injury, and 7. identify and implement system issues that can prevent further incidents. ... ""... Other investigative activities may include but are not limited to the following: 1. An interview with the person(s) reporting the incident, documented on the appropriate witness statement form; 2. Interviews with any witnesses to the incident and their written statements; 3. A private interview with the resident if the resident is able to be interviewed; 4. A review of the medical record or other documents relevant to the investigation; 5. Interviews with staff members who may have had contact with the resident during the time of the alleged incident; 6. Interviews with other residents who may have had contact with the staff member during the time of the alleged incident; and/or 7. Assessment of the resident's physical, psychological and mental status. ""The facility will protect residents from further harm during any investigation. This can be achieved by identifying any person(s) that the resident feels is causing harm and remove them from duty pending the investigation. The Social Services Supervisor or designee shall monitor and document the resident's feelings regarding the incident, reporting any concerns to the resident's family and/or physician if indicated. ..."" ""The Executive Director or his/her designee will complete a chronological narrative of the investigation describing the allegation, the investigation and the conclusion based on the facts of the situation. The conclusion should state the reasons the determination was made, whether or not the allegation was substantiated or unsubstantiated, any external reporting that was completed in conjunction with the investigation, any employee education that occurred, any employee discipline that occurred as a result of the investigation, any system changes that were made due to the outcome and any communication with residents or responsible parties related to the investigation. This narrative should become part of the internal investigative file and be signed and dated by the investigator. ..."" -- 7. The facility failed to execute these steps outlined in the policy as follows: - The facility did not look thoroughly into each allegation of abuse / neglect to determine if the allegation actually occurred. There was no evidence that follow-up questions were asked of staff when they revealed, in their witness statements and/or responses to a pre-determined set of interview questions, knowledge of abuse / neglect by Employee #81, in an effort to collect more information. In addition, they did not analyze the information they did collect to make informed determinations. - There was no evidence the facility examined Resident #12 for clinical signs of injuries after discovering Employee #81 had performed the invasive procedure. The facility had knowledge that Employee #81 digitally removed stool from the resident's rectum without a physician's order. Medical record review and staff interview revealed the facility had no documentation to reflect any intervention had been offered to Resident #12 after learning of this occurrence. - The facility had knowledge that Employee #81 had allowed nursing assistants to administer medications, perform finger sticks for diabetic residents, give insulin injections, change oxygen tubing (which may involve adjusting the flow rate of oxygen if tubing were changed on a resident receiving oxygen continuously; oxygen is a medical gas requiring a physician's order for administration), as well as administer skin treatments. However, the facility did not identify and assess those residents potentially affected by these practices. - While the facility substantiated an allegation that Employee #81 administered laxatives to residents without physician's orders, there was no evidence to reflect efforts by the facility to identify the residents affected by this practice, in order to perform clinical examinations to assess for possible physical harm - especially in view of the allegations by other LPNs that Employee #81 administered to residents a custom-made combination of laxatives in which [MEDICATION NAME] was used in excessive doses. - There was no evidence to reflect the facility did not look into causative factors to help determine why so many employees failed to report their knowledge of abuse. Employees reported in their statements that they felt afraid of Employee #81, but the facility did not take this information and implement measures to ensure the employees would not fail to report in the future out of fear of reprisal. - The administrator, when interviewed, said other residents who received care from Employee #81 were not interviewed. Residents #59, #60, #61, #62, #15, #30, and #12 were not interviewable due to cognitive impairments. Although the residents abused / neglected by Employee #81 were noted to have cognitive impairments, residents with no cognitive impairments would have been able to participate in interviews to inquire into some of the allegations, such as whether Employee #81 slammed doors and yelled at other residents during night shift or whether they received fingersticks, insulin injections, or other medications by non-licensed staff at night. - The facility did not complete chronological narratives on each of the allegations made against Employee #81. Multiple responses collected from employees to pre-determined sets of interview questions were not dated. The narratives (which were also not dated) did not specify the reasons why allegations were determined to be unsubstantiated. The narratives did not contain information on external reporting made by the facility. Employee education and discipline were also not part of this chronological narrative, as required by the facility's policy and procedures. - With respect to notifying the physician and family of the mistreatment / abuse / neglect experienced by Residents #12, #15, #30, #59, #60, #61, #62, and X, the administrator reported she had contacted both the physician and the responsible parties; however, documentation to support th",2014-10-01
10999,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,226,E,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to develop and operationalize policies and procedures for training employees; protection of residents; and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, for the purpose of assuring the facility is doing all that is within its control to prevent such occurrences. The facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations (to include efforts to identify as many affected residents as possible) and draw the appropriate conclusions based on the information available to them; and (4) develop and implement measures to ensure staff immediately reported their knowledge related to allegations of resident mistreatment / abuse / neglect without fear of reprisal. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when the events were witnessed by two (2) other staff members, and no reasons for making these determinations were documented. After the facility became aware that staff did not immediately report these allegations to supervisory / administrative personnel in the facility due to fear of reprisal by Employee #81, the facility did not implement any measures to address how to overcome this barrier to ensure timely reporting in the future. The facility's failure to operationalize its policy and procedures related to abuse prohibition is an on-going deficient practice and has the potential to affect all residents in the facility. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and an unidentified resident who was no longer at the facility (""X""). Employee identifiers: #5, #50, #51, #35, #58, #59, #67, #71, #72, #73, #74, #75, #79, #80, and #81. Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and ""X"" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - ""Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone."" (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - ""Employee was alleged to have squirted water on resident (#62). ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee tied resident's (#30) wheelchair to side rail. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#61) to yell and cuss. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that this employee placed cold water on the resident's face (#62). ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee was verbally inappropriate to residents."" (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee put resident (#60) to bed in a rough manner. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #30)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #12)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds."" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30 ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..."" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..."" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)"" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them."" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/23/10 by Employee #79 (a CNA): ""I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- 3. Failure to Meet Reporting Requirements Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their ""scope of practice"", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident ""X"" to keep them from falling -- Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. -- 4. After reviewing witness statements collected from employees by the facility, it was unclear why some of the allegations were not substantiated by the facility: - Employees #74, #73, #50, #79, and #51 reported witnessing (or participating in) nursing assistants performing duties for which they were not trained, including invasive procedures (i.e., fingersticks and insulin injections). The facility did not report or investigate these allegations. - Employees #74, #67, and #51 reported having witnessed Employee #81 throw water, shoot water or saline with a syringe, or spray water on residents. The facility did not substantiate these allegations. - Employees #73 and #74 both reported having witnessed Employee #81 slamming residents' doors and yelling at residents at night when residents were sleeping. The facility did not report or investigate this allegation. - Employees #51 and #73 both reported having witnessed Employee #81 holding Resident #12's nose and/or mouth closed in order to get the resident to swallow medications, food and/or fluids. The facility did not investigate or substantiate this allegation. - Employee #74 reported having witnessed Employee #81 hold residents' noses closed and pry open their mouths to give them medications. The facility did not question Employee #74 to determine the name(s) of the resident(s) she observed. - Employee #73 reported having witnessed Employee #81 record her initials in residents' records to indicate she administered medications to them, but she did not give the residents these medications. The facility did not question Employee #73 as to which residents were affected. - Employee #67 reported having witnessed Employee #81 tie garbage bags around Resident #12 and Resident X to keep them from falling. The facility did not report or investigate allegations of involuntary seclusion involving Resident X (whose first name only was provided in Employee #67's written statement). - The executive director (administrator), when interviewed on the afternoon of 06/09/11, had no further information related to the investigations. She stated she had completed the investigations with the assistance of Employee #35 (social services supervisor) and felt they were thorough and complete at the time. -- 5. The facility's titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09) stated, on Pages 2 and 3: ""- Training will be provided to all employees, through orientation and ongoing sessions, (upon hire and at least annually) and will include but not be limited to the following: 1. the AMFM, Inc. abuse, neglect, involuntary seclusion, and misappropriation of property prohibition policy; 2. what constitutes abuse, neglect, and misappropriation of resident property; 3. how staff should report their knowledge related to allegations without fear of reprisal; 4. appropriate interventions to address and or deal with aggressive and/or inappropriate reactions of residents; 5. how to recognize signs of frustration and stress that lead to abuse; and 6. the statutory requirement of all employees to report abuse and neglect of a resident. "" ""- Prevention of abuse, neglect, involuntary seclusion, and misappropriation of property shall include but not be limited to the following: 1. Educating residents, families and staff with information on the reporting process of allegations, concerns, incidents, and grievances. This education shall also include the knowledge that communicating any of the above will not result in reprisal or any form of retribution. Staff will also provide feedback and/or follow up regarding concerns that have been expressed. 2. The staff shall also be educated in identifying, correcting and intervening in situations in which abuse, neglect and/or misappropriation of customer property may be more likely to occur. ... ""... 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 then to immediately report it to his/her immediate supervisor. ""...The family / responsible party and attending physician shall be notified and recommendation(s) shall be followed. Documentation of notifications, recommendations and actions taken shall be documented as part of the investigation. ... "" Beginning on Page 4 of the policy and procedures, under the heading ""D. Investigation"", was found: ""Upon receiving information regarding an allegation of abuse or neglect the Executive Director or designee shall: ""Immediately refer to the Step One: Decision Tree for Determining the Reportability of an Incident or Allegation and Step Two: Internal and External Notification of A Reportable Incident or Allegation (see Tables 1 and 2) to assure notification if the event is reportable and initiate an investigation. ""Report the allegation(s) to the appropriate state agencies within the required time frames (see Tables 3 and 4). ""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: 1. determine if the alleged abuse or neglect occurred and to what extent, 2. clinical examination for signs of injuries, if indicated, 3. a review of AMFM, Inc. policies that are related to the incident, 4. causative factors, trends, 5. determine the root cause of the incident, 6. identify interventions to prevent further injury, and 7. identify and implement system issues that can prevent further incidents. ... ""... Other investigative activities may include but are not limited to the following: 1. An interview with the person(s) reporting the incident, documented on the appropriate witness statement form; 2. Interviews with any witnesses to the incident and their written statements; 3. A private interview with the resident if the resident is able to be interviewed; 4. A review of the medical record or other documents relevant to the investigation; 5. Interviews with staff members who may have had contact with the resident during the time of the alleged incident; 6. Interviews with other residents who may have had contact with the staff member during the time of the alleged incident; and/or 7. Assessment of the resident's physical, psychological and mental status. ""The facility will protect residents from further harm during any investigation. This can be achieved by identifying any person(s) that the resident feels is causing harm and remove them from duty pending the investigation. The Social Services Supervisor or designee shall monitor and document the resident's feelings regarding the incident, reporting any concerns to the resident's family and/or physician if indicated. ... "" ""The Executive Director or his/her designee will complete a chronological narrative of the investigation describing the allegation, the investigation and the conclusion based on the facts of the situation. The conclusion should state the reasons the determination was made, whether or not the allegation was substantiated or unsubstantiated, any external reporting that was completed in conjunction with the investigation, any employee education that occurred, any employee discipline that occurred as a result of the investigation, any system changes that were made due to the outcome and any communication with residents or responsible parties related to the investigation. This narrative should become part of the internal investigative file and be signed and dated by the investigator. ... "" -- 6. The facility failed to execute these steps outlined in the policy as follows: - The facility did not look thoroughly into each allegation of abuse / neglect to determine if the allegation actually occurred. There was no evidence that follow-up questions were asked of staff when they revealed, in their witness statements and/or responses to a pre-determined set of interview questions, knowledge of abuse / neglect by Employee #81, in an effort to collect more information. In addition, they did not analyze the information they did collect to make informed determinations. - There was no evidence the facility examined Resident #12 for clinical signs of injuries after discovering Employee #81 had performed the invasive procedure. The facility had knowledge that Employee #81 digitally removed stool from the resident's rectum without a physician's order. Medical record review and staff interview revealed the facility had no documentation to reflect any intervention had been offered to Resident #12 after learning of this occurrence. - The facility had knowledge that Employee #81 had allowed nursing assistants to administer medications, perform finger sticks for diabetic residents, give insulin injections, change oxygen tubing (which may involve adjusting the flow rate of oxygen if tubing were changed on a resident receiving oxygen continuously; oxygen is a medical gas requiring a physician's order for administration), as well as administer skin treatments. However, the facility did not identify and assess those residents potentially affected by these practices. - While the facility substantiated an allegation that Employee #81 administered laxatives to residents without physician's orders, there was no evidence to reflect efforts by the facility to identify the residents affected by this practice, in order to perform clinical examinations to assess for possible physical harm - especially in view of the allegations by other LPNs that Employee #81 administered to residents a custom-made combination of laxatives in which [MEDICATION NAME] was used in excessive doses. - There was no evidence to reflect the facility did not look into causative factors to help determine why so many employees failed to report their knowledge of abuse. Employees reported in their statements that they felt afraid of Employee #81, but the facility did not take this information and implement measures to ensure the employees would not fail to report in the future out of fear of reprisal. - The administrator, when interviewed, said other residents who received care from Employee #81 were not interviewed. Residents #59, #60, #61, #62, #15, #30, and #12 were not interviewable due to cognitive impairments. Although the residents abused / neglected by Employee #81 were noted to have cognitive impairments, residents with no cognitive impairments would have been able to participate in interviews to inquire into some of the allegations, such as whether Employee #81 slammed doors and yelled at other residents during night shift or whether they received fingersticks, insulin injections, or other medications by non-licensed staff at night. - The facility did not complete chronological narratives on each of the allegations made against Employee #81. Multiple responses collected from employees to pre-determined sets of interview questions were not dated. The narratives (which were also not dated) did not specify the reasons why allegations were determined to be unsubstantiated. The narratives did not contain information on external reporting made by the facility. Employee education and discipline were also not part of this chronological narrat",2014-10-01
11000,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,250,E,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed provide medically-related social services, in accordance with facility policy, to eight (8) residents who were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them combinations of laxatives that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The facility did not provide medically-related social services to these residents after learning they had been named as subjects of mistreatment / abuse / neglect. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and ""X"". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and ""X"" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - ""Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone."" (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - ""Employee was alleged to have squirted water on resident (#62). ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee tied resident's (#30) wheelchair to side rail. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#61) to yell and cuss. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that this employee placed cold water on the resident's face (#62). ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee was verbally inappropriate to residents."" (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee put resident (#60) to bed in a rough manner. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #30)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #12)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds."" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 Bisacodyls - 30 ccs Mylanta & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..."" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..."" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)"" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them."" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much Bisacodyl (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid Mylanta. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""... Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- 3. Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 discomfort and distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's physical discomfort and/or emotional distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. -- 4. A review of the medical records for Residents #12, #15, #30, #59, #60, #61, and #62 and internal investigative files related to Employee #81 found no evidence that medically-related social services had been provided to these residents after the facility substantiated the allegations against Employee #81. (The eighth resident - Resident X - was not identified by the facility during the course of its investigation.) There was no evidence to reflect the facility had assessed the residents to ascertain whether each resident's physical, mental, or psychosocial status had been impacted, such as changes in activity level, meal intake, mood, sleep cycle, and/or behaviors. The administrator verified there was no documentation to reflect the facility had provided medically-related social services to the seven (7) residents listed above. .",2014-10-01
11001,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,490,F,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility 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. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report contributed to a systemic failure of the facility's abuse prohibition program. The administrator, director of nursing (DON), and social worker, who were involved in the facility's internal investigation of Employee #81's actions, were made aware, through witness statements, that employees failed to immediately report Employee #81's actions due to their fear of Employee #81. They failed, however, identify this as a root cause of the failure of the abuse prohibition program, and no measures were developed and implemented to ensure employees, going forward, would not delay reporting of abuse / neglect out of fear of reprisal. The facility also failed to fully implement other components of its policy and procedures related to abuse prohibition, to include thorough investigation of alleged abuse / neglect, notification of the physician and responsible party of affected residents, and the provision of medically-related social services to affected residents. The facility's failure to identify / address root causes of its failure to operationalize policy and procedures related to abuse prohibition has the potential to affect all residents in the facility. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and an unidentified resident who was no longer at the facility (""X""). Facility census: 58. Findings include: a) Resident Abuse Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and ""X"". (See citation at F223 for additional information.) -- b) Failure to Immediately Report and Thoroughly Investigate Allegations of Abuse / Neglect The facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations and draw the appropriate conclusions based on the information available to them; and (4) report to all State agencies those individuals who had knowledge of the abuse / neglect by Employee #81 and both failed to intervene to protect the residents from further abuse / neglect and failed to fulfill their roles as mandatory reporters. Eleven (11) employees had knowledge of abuse / neglect occurring to residents in the facility and did not report this to their supervisor, to their administrator, or to any outside agency responsible for receiving reports of abuse / neglect in nursing homes. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when events were witnessed by two (2) other staff members, and no reasons for making these determinations were documented. (See citation at F225 for additional information.) -- c) Failure to Operationalize Policies and Procedures Related to the Facility's Abuse Prohibition Program The facility failed to develop and operationalize policies and procedures for training employees; protection of residents; and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, for the purpose of assuring the facility is doing all that is within its control to prevent such occurrences. After the facility became aware that staff did not immediately report these allegations to supervisory / administrative personnel in the facility due to fear of reprisal by Employee #81, the facility did not implement any measures to address how to overcome this barrier to ensure timely reporting in the future. The facility also did not conduct a root cause analysis after the investigation into allegations against Employee #81, thereby failing to recognize that all elements of its policy and procedures related to the abuse prohibition program were not being implemented. Non-compliance with this requirement is on-going as evidenced by failure of the facility to ensure investigations into all allegations of resident abuse / neglect are thoroughly documented in a chronological narrative which includes the reason(s) why determinations were made to substantiate or not substantiate each allegation. None of the internal investigative files reviewed by the surveyor from January 2010 to present contained all of the elements required by the facility's policy and procedures. (See citation at F226 for additional information.) -- d) Failure to Notify Physicians and Responsible Parties of Affected Residents The facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff, as required by facility policy. (See citation at F157 for additional information.) -- e) Failure to Provide Medically-Related Social Services to Affected Residents The facility failed provide medically-related social services, in accordance with facility policy, to eight (8) residents who were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). A review of the medical records for Residents #12, #15, #30, #59, #60, #61, and #62 and internal investigative files related to Employee #81 found no evidence that medically-related social services had been provided to these residents after the facility substantiated the allegations against Employee #81. There was no evidence to reflect the facility had assessed the residents to ascertain whether each resident's physical, mental, or psychosocial status had been impacted, such as changes in activity level, meal intake, mood, sleep cycle, and/or behaviors. This was verified during an interview with the administrator on the afternoon of 06/09/11. (See citation at F250 for additional information.) -- f) During an interview with the administrator on 06/09/11 at approximately 2:30 p.m., she verified the facility had not conducted staff education on issues such as mandatory reporting abuse and neglect as well as reporting abuse and neglect against co-workers / supervisors when fearing retaliation. According to the administrator, the employees involved in the above allegations informed her they did not report their knowledge of abuse and neglect because they were afraid of the repercussions they would face from Employee #81. The administrator agreed the facility should have ascertained the training needs of its employees at the conclusion of the January 2010 investigations and provided education at that time. She acknowledged that, as of this date (06/09/11), the facility had not yet provided any education on the key employee reporting problems identified during the investigation. She presented an agenda of future inservice education, which included mandatory reporting requirements as well as, reporting witnessed resident abuse / neglect or information about resident abuse / neglect by employees who intimidate and bully those who witness or have knowledge of the abuse / neglect to try and prevent those witnesses from reporting. -- g) Key members of the facility's management staff who were involved in the internal investigations of allegations made against Employee #81 were the administrator, the DON, and the social worker. .",2014-10-01
11002,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,520,F,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to develop and implement action plans to correct quality deficiencies of which the committee should have known with respect to implementation of the facility's abuse prohibition program. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report contributed to a systemic failure of the facility's abuse prohibition program. Members of the QAA committee who were involved in the facility's internal investigation of Employee #81's actions (the administrator, director of nursing, and social worker) were made aware, through witness statements, that employees failed to immediately report Employee #81's actions due to their fear of Employee #81. The QAA committee did not, however, identify this as a root cause of the failure of the abuse prohibition program and did not develop and implement measures to ensure employees, going forward, would not delay reporting of abuse / neglect out of fear of reprisal. The facility also failed to fully implement other components of its policy and procedures related to abuse prohibition of which the QAA committee should have been aware, to include thorough investigation of alleged abuse / neglect, notification of the physician and responsible party of affected residents, and the provision of medically-related social services to affected residents. The QAA committee's failure to identify and address root causes of the facility's failure to operationalize its policy and procedures related to abuse prohibition has the potential to affect all residents in the facility. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and an unidentified resident who was no longer at the facility (""X""). Facility census: 58. Findings include: a) Resident Abuse Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and ""X"". (See citation at F223 for additional information.) -- b) Failure to Immediately Report and Thoroughly Investigate Allegations of Abuse / Neglect The facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations and draw the appropriate conclusions based on the information available to them; and (4) report to all State agencies those individuals who had knowledge of the abuse / neglect by Employee #81 and both failed to intervene to protect the residents from further abuse / neglect and failed to fulfill their roles as mandatory reporters. Eleven (11) employees had knowledge of abuse / neglect occurring to residents in the facility and did not report this to their supervisor, to their administrator, or to any outside agency responsible for receiving reports of abuse / neglect in nursing homes. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when the events were witnessed by two (2) other staff members, and no reasons for making these determinations were documented. (See citation at F225 for additional information.) -- c) Failure to Operationalize Policies and Procedures Related to the Facility's Abuse Prohibition Program The facility failed to develop and operationalize policies and procedures for training employees; protection of residents; and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, for the purpose of assuring the facility is doing all that is within its control to prevent such occurrences. After the facility became aware that staff did not immediately report these allegations to supervisory / administrative personnel in the facility due to fear of reprisal by Employee #81, the facility did not implement any measures to address how to overcome this barrier to ensure timely reporting in the future. The facility also did not conduct a root cause analysis after the investigation into allegations against Employee #81, thereby failing to recognize that all elements of its policy and procedures related to the abuse prohibition program were not being implemented. Non-compliance with this requirement is on-going as evidenced by failure of the facility to ensure investigations into all allegations of resident abuse / neglect are thoroughly documented in a chronological narrative which includes the reason(s) why determinations were made to substantiate or not substantiate each allegation. None of the internal investigative files reviewed by the surveyor from January 2010 to present contained all of the elements required by the facility's policy and procedures. (See citation at F226 for additional information.) -- d) Failure to Notify Physicians and Responsible Parties of Affected Residents The facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff, as required by facility policy. (See citation at F157 for additional information.) -- e) Failure to Provide Medically-Related Social Services to Affected Residents The facility failed provide medically-related social services, in accordance with facility policy, to eight (8) residents who were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). A review of the medical records for Residents #12, #15, #30, #59, #60, #61, and #62 and internal investigative files related to Employee #81 found no evidence that medically-related social services had been provided to these residents after the facility substantiated the allegations against Employee #81. There was no evidence to reflect the facility had assessed the residents to ascertain whether each resident's physical, mental, or psychosocial status had been impacted, such as changes in activity level, meal intake, mood, sleep cycle, and/or behaviors. This was verified during an interview with the administrator on the afternoon of 06/09/11. (See citation at F250 for additional information.) -- f) During an interview with the administrator on 06/09/11 at approximately 2:30 p.m., she verified the facility had not conducted staff education on issues such as mandatory reporting abuse and neglect as well as reporting abuse and neglect against co-workers / supervisors when fearing retaliation. According to the administrator, the employees involved in the above allegations informed her they did not report their knowledge of abuse and neglect because they were afraid of the repercussions they would face from Employee #81. The administrator agreed the facility should have ascertained the training needs of its employees at the conclusion of the January 2010 investigations and provided education at that time. She acknowledged that, as of this date (06/09/11), the facility had not yet provided any education on the key employee reporting problems identified during the investigation. She presented an agenda of future inservice education, which included mandatory reporting requirements as well as, reporting witnessed resident abuse / neglect or information about resident abuse / neglect by employees who intimidate and bully those who witness or have knowledge of the abuse / neglect to try and prevent those witnesses from reporting. -- g) Key members of the facility's QAA committee who were involved in the internal investigations of allegations made against Employee #81 were the administrator, the director of nursing, and the social worker.",2014-10-01
11003,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,157,E,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff. Resident identifiers: #12, #15, #30, #59, #60, #62, #61, and an unidentified resident who was no longer at the facility (""X""). Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #62, #61, and X 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed the following allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency: - Employee #81 was alleged to have audio-taped Resident #12 on her cell phone as she cursed (Reported to State survey agency on 01/25/10; date of incident was not known) - Employee #81 was alleged to have squirted water on Resident #62 (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have pushed Resident #15 quickly down the hallway in her wheelchair (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #12 to ""yell and cuss"" and to have given medications to this resident in an ""inappropriate manner"" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #61 to ""yell and cuss"" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have tied Resident #30's wheelchair to a side rail (Reported to state survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have put Resident #60 to bed in a ""rough manner"" (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to be ""verbally inappropriate"" to various unidentified residents (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to have used ""inappropriate restraints"" on Resident #12 (Reported to state survey agency on 01/28/10; date of incident was not known) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated the following allegations: - Administering medications (laxatives) to an unidentified number of residents without a physician's order - Recording the voice of Resident #12 as she screamed and cursed while Employee #81 digitally removed stool from her rectum, and playing the recording for others to hear - Encouraging Residents #12 and #61 to curse - Tying Resident #30's wheelchair to a rail for staff convenience, to keep the resident from wandering -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) - In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds. "" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ... "" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ... "" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61) "" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them. "" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""... Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in /wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- Review of Resident #12's medical record, including nursing notes and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status (including signs / symptoms of the presence of a fecal impaction necessitating this procedure), and no nursing note entries detailing the performance of the procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 discomfort and distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. -- The facility's titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09) stated, on Page 3: "" ...The family / responsible party and attending physician shall be notified and recommendation(s) shall be followed. Documentation of notifications, recommendations and actions taken shall be documented as part of the investigation. ... With respect to notifying the physician and family of the mistreatment / abuse / neglect experienced by Residents 59, #60, #61, #62, #15, #30, and #12, the administrator reported, on the afternoon of 06/09/11, that she had contacted both the physician and the responsible parties; however, documentation to support this could not be located. .",2014-10-01
11004,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-08-17,492,C,1,0,2TQ312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the statement of deficiencies and plan of correction (CMS-2567) from the 06/09/11 complaint investigation # , staff interview, and review of WV Legislative Rule 10-2, the facility failed to report to the West Virginia State Board of Examiners for Licensed Practical Nurses when five (5) of five (5) licensed practical nurses (LPNs - Employees #74, #58, #73, #59, and #51) failed to report knowledge of abuse of facility residents. This deficient practice did affect four (4) facility residents and had the potential to affect all residents currently residing in the facility. Resident identifiers: #12, #62, #30, and #60. Facility census: 58. Findings include: a) Employee #74 Review of the CMS-2567 from the 06/09/11 complaint investigation # found that an internal investigation conducted by the facility during the month of January 2010 determined LPNs at the facility had knowledge of abuse perpetrated against residents by another LPN identified as Employee #81. In a witness statement obtained by the facility on 01/22/10, Employee #74 admitted having knowledge of Employee #81 recording the screams, curses and other noises made by Resident #12 when Employee #81 digitally removed a fecal impaction without a physician's orders [REDACTED]. Employee #74 further admitted having knowledge of Employee #81 giving residents too many laxatives and referring to the administration of 4 [MEDICATION NAME], 30 cc [MEDICATION NAME] and 30 cc Milk of Magnesia, without a physician's orders [REDACTED]. Employee #74 further admitted having knowledge of Employee #81 allowing unlicensed and untrained nursing assistants (NA) to administer insulin, do finger sticks, and administer medications. Employee #74 did not report this knowledge of abuse immediately as required. -- b) Employee #58 In a witness statement obtained by the facility on 01/22/10, Employee #58 admitted having knowledge of Employee #81 allowing unlicensed and untrained NAs administer medications and finger sticks for glucose levels. She further admitted having knowledge of Employee #81 getting some of the residents ""rowled"" up and laugh about it. -- c) Employee #73 In a witness statement obtained by the facility on 01/23/10, Employee #73 admitted having knowledge of Employee #81 recording the sounds made while having an impaction digitally removed. She admitted having knowledge of Employee #81 holding Resident #12's nose to give medications when she would not take them. Employee #73 further admitted having knowledge of Employee #81 taking a resident who was frightened of water (Resident #62) to the shower and spraying cold water into the resident's face. Employee #73 did not report this knowledge of abuse by Employee #81 as required. -- d) Employee #59 In a statement obtained by the facility on 01/23/10, Employee #59 admitted having knowledge of Employee #81 recording the sounds made by Resident #12 during the removal of an impaction and playing it for other employees. Employee #59 admitted knowledge of Employee #81 pouring cold water on Resident #59, and picking Resident #60 up and throwing her into the bed until she hit the wall. Employee #59 did not report this knowledge of resident abuse as required. -- e) Employee #51 In a statement collected by the facility on 01/23/10, Employee #51 admitted having knowledge of Employee #81 abusing facility residents. Employee #51 did not report this abuse as required. -- f) Review of the facility's abuse and neglect reporting found the five (5) LPNs who failed to report knowledge of abuse were not reported to the LPN licensing board for failing to follow established policies and procedures in the practice setting to safeguard patient care (Title 10 Legislative Rules West Virginia State Board of Examiners for Licensed Practical Nurses Series 2 Policies Regulating Licensure of the Licensed Practical Nurse, section 10-2-12.1.e12. -- g) Interviews with the director of nursing (DON) and the administrator, on the morning of 08/17/11, confirmed that the facility did not report Employees #74, #58, #73, #59, and #51 to the Board of Examiners for Licensed Practical Nurses for their failure to report their knowledge of resident abuse to prevent further abuse by Employee #81.",2014-10-01
11005,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-06-29,225,E,1,0,PJJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's grievance / complaints reports and staff interview, the facility failed thoroughly investigate and/or immediately report allegations of neglect to the appropriate State agencies. Review of the facility's grievance / complaints reports found twelve (12) allegations of neglect involving nine (9) which were not thoroughly investigated and/or reported to the appropriate State agencies. Resident identifiers: #48, #20, #9, #92, #5, #100, #74, #108, #28, #26. Facility census: 113. Findings include: a) Resident #26 Review of the facility's reportable complaints, and other grievance concerns revealed the facility failed to thoroughly investigate and/or immediately report allegations of neglect. Record review revealed Resident #26 was unable to communicate related to complications of a [DIAGNOSES REDACTED]. She had a gastrostomy tube ([DEVICE]), and her medication orders included [MEDICATION NAME] 125 mg via [DEVICE] twice daily to treat a [MEDICAL CONDITION] disorder. On 04/08/11, Resident #26 had a critically low blood level of [MEDICATION NAME] at 2.8 mcg/ml, with a normal therapeutic range of 10 to 20 mcg/ml. When notified of this lab result, the facility contacted the physician, who increased the resident's dose of [MEDICATION NAME] to 250 mg twice daily and ordered a follow-up lab. On 04/12/11, her blood level of [MEDICATION NAME] was still below the therapeutic range at 7.4 mcg/ml, and the physician increased her [MEDICATION NAME] to 250 mg in the morning and 500 mg at bedtime. Repeat lab work, on 04/19/11, found Resident #26 now had a critically high blood level of [MEDICATION NAME] at 35.3 mcg/ml, and the physician ordered that the night-time dose of [MEDICATION NAME] be held and to restart the dose at 250 mg twice daily in the morning. Repeat lab work on 04/26/11 and 05/05/11 continued to identify critically high blood levels of [MEDICATION NAME], and adjustments were made to her medication regimen until labs came back on 05/15/11 showing her [MEDICATION NAME] level was 17.7 mcg/ml (within the therapeutic range). According to the director of nursing (DON - Employee #1) when interviewed at 2:15 p.m. on 06/28/11, the facility did not suspect that Resident #26 was not receiving her [MEDICATION NAME] as ordered until one day when a nurse (Employee #114) was accused on not opening the syringe to administer the resident's medications via the [DEVICE]; therefore, the facility assumed she had not given the medications. The DON counted Resident #26's [MEDICATION NAME] tablets before and after Employee #114 completed her morning medication pass on 04/13/11, and the DON found the number of [MEDICATION NAME] tablets remained at the same count after the medication pass was completed. Employee #114 reported she had given the medication but that she had to borrow it from another resident who took the same dose of [MEDICATION NAME], because Employee #114 said she could not find the [MEDICATION NAME] for Resident #26. Employee #114 was subsequently terminated and reported to her nursing licensing board. Review of Resident #26's April 2011 Medication Administration Record [REDACTED]. There were no documented medication omissions. Employee #114 would have only been responsible for administering the morning dose of [MEDICATION NAME], but she only worked five (5) days in April and would have been responsible for only five (5) of twenty-five (25) scheduled doses to have been administered between the morning of 04/01/11 and the morning of 04/13/11. Interview with the facility's consultant pharmacist, at 3:45 p.m. on 06/28/11, revealed several factors can affect the [MEDICATION NAME] level (e.g., a low [MEDICATION NAME] level), and only one (1) missed dose would not have given such a critical lab value. There was no evidence to reflect the facility had conducted a thorough investigation into missed doses of [MEDICATION NAME], as no nurses other than Employee #114 were investigated by the facility as possibly having failed to administer the [MEDICATION NAME] as ordered. The surveyor interviewed the other nurses and found that they had not been asked by the facility to give statements related to the incident. -- b) Residents #48, #20, #28, #95, #92, #100, #74, and #108 1. Resident #48 On 01/20/11, the former social worker (Employee #115) initiated a complaint from Resident #48. The resident alleged a nursing assistant (Employee #118 - no longer employed with the facility) took one (1) hour to come and clean her up after a bowel movement. The resident stated she no longer wanted this nursing assistant to care for her. The facility's resolution to the concern was to change the assignment so the alleged perpetrator did not have to care for this resident again. - 2. Resident #20 On 01/20/11, a family member of Resident #20 complained to Employee #115 that, when her brother came to visit her mother (Resident #20), her mother's roommate had bowel movement all over her bed, the floor, and herself. The facility's resolution to the problem was to move Resident #20 to another room. No evidence could be found related to any type of investigation of the incident reported. On 05/20/11, Resident #20 reported to the assessment nurse (Employee #53) that her bedside commode was not always emptied after she urinated in it. The facility in-serviced staff related to cleaning bedside commodes. No further investigation was completed. On 05/20/11, Resident #20 reported to Employee #53 that, when she was transferred to the bedside commode, she was not always given her call light. She reported that she sits on the bedside commode for a long time before someone comes back. The facility's resolution to the incident was again to in-service staff. No further investigation into the concern could be found. - 3. Resident #28 On 02/10/11, Resident #28's sister (Resident #50, also a resident at the facility) stated staff was not getting her brother (#28) dressed and assisting him with hygiene during the morning. Resident #50 stated she could no longer help her brother with his hygiene needs. - 4. Resident #95 On 03/01/11, the representative for Resident #95 made a complaint to the Resident #115 related to Resident #95's eyes not being cleaned. The nursing assistant stated, ""We are short staffed."" The facility's resolution to the issue was to in-service their staff. No further investigation was found related to the allegation. - 5. Resident #92 On 04/15/11, Resident #92 reported staff did not answer her call light for thirty (30) minutes and she wet her bed. The facility's resolution to the issue was educate the staff on answering call lights. No further investigation into the incident could be found. - 6. Resident #100 On 04/26/11, Resident #100 told his sister that, on Friday 04/22/11, he pushed his call light for assistance in going to the bathroom. No one responded, and he a bowel movement in his pants. He further stated he waited an additional thirty (30) minutes for someone to come and clean him up. The facility did not further investigate the allegation, but they did schedule an appointment with the ombudsman and stated that they had educated staff on answering call lights. No further investigations were found. On 04/26/11, Resident #100 stated he had not been getting his showers. Resident #100's girlfriend was in to visit Resident #100 and, on Saturday 04/23/11, she reported to his sister that he was filthy and she could not get staff to help clean him up. Resident #100's girlfriend cleaned him up herself. This allegation was reported to Employee #114. - 7. Resident #74 Resident #74 complained to social services (Employee #86), on 04/28/11, that a nursing assistant came into his room. He asked her to clean him up, as he had a bowel movement. According to the grievance / complaint report, Resident #74 had bowel movement on him and his bed. The resident reported that the nurse aide walked out and did not provide assistance. Resident #74 then wheeled himself to the social service office and filed this complaint. No evidence could be found related to an investigation into the allegation. - 8. Resident #108 On 05/18/11, Resident #108 reported to the corporate social worker coordinator that her bedside commode was ""filthy"" and had not been cleaned ""well"". The facility's resolution was to notify the aide and clean the bedside commode and in-service staff. No further investigation was completed. - 9. On 06/29/11 at 11:55 a.m., an interview was held with the social services supervisor (Employee #86) and the corporate social work consultant (Employee #117) related to the above allegations. During this meeting, it was confirmed the facility had not reported to the allegations to the appropriate State agencies. .",2014-10-01
11006,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-06-29,441,D,1,0,PJJB11,". Based on observation, staff interview, and policy review, the facility failed to maintain an infection prevention and control program in order to prevent and control the onset and spread of infection within the facility. On 06/27/11 during a tour of the facility, a full (unclean) suction cannister and suction machine was found on the bedside table of one (1) of five (5) sampled residents. Resident identifier: 100. Facility census: 113. Findings include: a) Resident #100 During tour of the facility on the early afternoon of 06/27/11, observation found a full (unclean) suction cannister and suction machine with tubing was found on the bedside table in the room of Resident #100. The licensed practical nurse (LPN) for the D Hall (Employee #13) was immediately contacted. Employee #13 stated, ""(Employee #54) must have used it last night and left it here. I don't know the rules around here."" She further stated, ""I haven't had to use it today."" The director of nursing (DON - Employee #1) was notified of the finding at 3:25 p.m. on 06/27/11. She stated, ""Yes, this is an infection control issue."" The DON emptied and cleaned the cannister and removed it from the room. According to the facility's policy on suctioning, the suction machine should be left at bedside. If not needed, it should be disinfected and new supplies placed on it. The policy further states all equipment should be properly disposed of or disinfected after each resident use.",2014-10-01
10864,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,152,D,0,1,IPRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure one (1) of eleven (11) residents received a re-evaluation in their capacity status after a determination of short term incapacity had been made in 02/06/09. Resident identifier: #51. Facility census: 61. Findings include: a.) Resident #51 On 12/08/09 at approximately 9:30 a.m., medical record review for Resident #51 revealed she lacked the capacity to understand and make her own medical decisions. This determination occurred on 02/06/09, at which time the physician selected ""short-term"" for the duration incapacity and listed [MEDICAL CONDITION] cardiovascular disease as the cause. The physician identified as the nature of incapacity that the resident could not process information. The physician's determination of capacity form allowed for periodic capacity review; however, the facility had not completed the periodic review for this resident. On 12/08/09 at approximately 9:45 a.m., Employee #87 (registered nurse) indicated the resident received treatment from a psychiatrist who comes to the facility. She provided copies of the psychiatrist's progress notes which reflected no change in the resident's mental capacity. On 12/08/09, the physician re-evaluated the resident, at which time he determined the resident now possessed the capacity to understand and make her own medical decisions. .",2014-11-01
10865,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,319,D,0,1,IPRG11,"Based on medical record review and staff interview, the facility failed to meet the psychosocial needs of one (1) of thirteen (13) sampled residents who displayed signs of depression. Resident identifier: #41. Facility census: 61. Findings include: a) Resident #41 The medical record for Resident #41, when reviewed on 12/10/09, disclosed a nursing note dated 09/11/09, which stated, ""Resident tearful, states I'm depressed, my family won't call or come to see me, won't write. I can't go home. I'm afraid I'll die alone. Attempted to notify (name). Niece and MPOA that (name) resident is feeling depressed. Unable to reach her at work. Message left at home with a male. Will request for her to call us back. Will request that they call or visit."" There were no further nursing notes describing the resident's condition or mental state until October 2009. On 12/10/09 at approximately 4:00 p.m., the social worker was interviewed regarding her involvement with the resident. She indicated she had not responded to this issue. A nursing note, dated 10/06/09, stated, ""Informed by CNA (certified nursing assistant) that resident made comment that she would like to kill herself. (Name of social worker) notified of residents statement."" During the same interview noted above, the social worker indicated she had talked to the resident, and the resident denied wanting to harm herself. The social worker had one (1) updated progress note to reflect her visit with the resident. There was no evidence of any further follow-up to assess the resident's mood state. On 12/11/09, the assistant administrator was interviewed regarding the 09/11/09 nursing note. She agreed more intervention needed to have taken place following the resident's negative statements. .",2014-11-01
10866,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,241,D,0,1,IPRG11,"Based on observations, the facility failed to ensure each resident was treated in a manner that maintained his or her dignity. A resident was assisted to bed and left sitting with her entire upper body exposed while a staff member left the room to find a gown. One (1) of thirteen (13) current residents on the sample was affected. Resident identifier: #45. Facility census: 61. Findings include: a) Resident #45 On 12/10/09 at 5:34 p.m., the resident stated she wanted to go back to bed. Staff was informed and came into the resident's room to assist her from her wheelchair onto her bed. The resident was assisted to sit on the side of her bed by Employee #92 (a registered nurse) and Employee #104 (a nursing assistant). The resident's top and bra were removed, leaving the resident's body exposed from the waist up. No efforts were made to cover the resident's upper body while Employee #104 left the room to find a gown. The resident sat on the side of the bed naked from the waist up for several minutes until Employee #104 returned with a gown. During this time, the door to the room was closed, but the cubicle curtain and the blinds on the window were not. .",2014-11-01
10867,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,315,D,0,1,IPRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, the facility failed to ensure each incontinent resident received care and services to prevent urinary tract infections. An employee was observed providing incontinence care in a manner that created a potential for introduction of microorganisms into the urinary meatus. One (1) of thirteen (13) current residents on sample was affected. Resident identifier: #45. Facility census: 61. Findings include: a) Resident #45 On 12/10/09 at 5:34 p.m., incontinence care was provided by a nursing assistant (Employee #104). The employee used the same surface of a washcloth to wipe across the resident's pubic area and then back and forth over the labia / urinary meatus at least four (4) times. On 11/29/09, the resident had received [MEDICATION NAME] for ten (10) days for a [DIAGNOSES REDACTED] pneumoniae urinary tract infection - a bacterium found in the normal flora of the mouth, skin, and intestines. .",2014-11-01
10868,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,253,B,0,1,IPRG11,"Based on observations, the facility failed to provide maintenance services to maintain an orderly interior. Walls in residents' rooms were damaged and/or had been repaired but not painted. Multiple rooms were affected. Facility census: 61. Findings include: a) During the initial tour of the facility and throughout the survey, observation found the walls in various residents' rooms were damaged. The damage appeared to have been caused by the raising and lowering of the residents' beds. Examples of the observed damages were (the list is representative, but not all inclusive): 1. Room 33 The wall behind the first bed, which faced the door to the hall, had gouges that were at least twelve (12) to eighteen (18) inches long, at least two (2) inches wide and at least one-half (1/2) inch deep. The backing of the drywall could be felt in some areas. 2. Room 30 The wall beside one (1) bed had been patched but not been painted. The patched area had new scarred areas. The other bed had gouges in the all next to the window and behind the head of the bed. .",2014-11-01
10869,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,514,D,0,1,GPSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's medical record was completed and accurately documented. There was no documentation to indicate why nurses' initials on a resident's Medication Administration Record [REDACTED]. Resident identifier: #99. Facility census: 100 Findings include: a) Resident #99 Review of Resident #99's medical record revealed an order for [REDACTED]. Employee #75, when interviewed at 5:45 p.m. on 06/15/09, reported this resident refused this medication. She verified circling around a nurse's initials meant the resident did not take this medication. Employee #68, when interviewed, identified there was usually another form that goes with the MAR indicated [REDACTED]. .",2014-11-01
10870,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,272,D,0,1,GPSU11,"Based on a review of the medical record and staff interview, the facility failed to conduct a thorough assessment of Resident #149's bladder functioning. This resident had an indwelling urinary catheter, and the resident's minimum data set assessment (MDS) triggered for further assessment through the urinary incontinence and indwelling catheter resident assessment protocol (RAP); however, there was no evidence this RAP was completed in accordance with Appendix C of the Resident Assessment Instrument User's Manual. This was true for one (1) of twenty-eight (28) sampled resident in Stage II of the survey. Resident identifier: #149. Facility census: 100. Findings include: a) Resident #149 Review of Resident #149's most recent comprehensive assessment revealed this resident had an indwelling Foley urinary catheter. In Section V of this MDS, the urinary incontinence and indwelling catheter RAP was checked to indicate the need for further assessment of triggered area. Review of the RAP summary, dated 06/12/09, for the use of this indwelling catheter, revealed the RAP documentation did not contain any assessment information related to the resident's need for an indwelling catheter. The RAP summary simply stated, ""The resident has a Foley catheter and has incontinent episodes."" This was not a thorough assessment of the resident's for the continued need of this indwelling catheter. The director of nursing (DON), when interviewed regarding a further assessment for the use of this catheter on 06/16/09 at 10:00 a.m., confirmed there was no further evaluation for the use of this indwelling catheter in the record. .",2014-11-01
10871,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,279,D,0,1,GPSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the medical record and staff interview, the facility failed to develop a plan of care to address the immediate care needs of a resident with an indwelling urinary catheter. The care plan did not contain specific information regarding the indwelling catheter, including the reason for its use, the size to be inserted, and the care to be provided to prevent complications associated with catheter use, including introduction of infectious organisms into the urinary tract. This was true for one (1) of twenty-eight (28) sampled residents in Stage II of the survey. Resident identifier: #149. Facility census: 100. Findings include: a) Resident #149 Review of Resident #149's medical record revealed this resident was admitted on [DATE]. Her admission physician's orders [REDACTED]. However, the order contained no instructions regarding the kind of catheter or the size to be used. Further review of the record revealed a care plan, dated 06/01/09, which stated, ""Resident has Foley catheter. Potential for appliance dysfunction and/or infection daily."" The goals for the use of this catheter included: ""No adverse reaction noted r/t (related to) dysfunction and no s/s (signs / symptoms) of infection noted daily through next review period."" There were the only two (2) interventions associated with these goals; these were: ""Change q (every) 30 days, and Foley care q shift."" During an interview on 06/17/09 at 10:00 a.m., the director of nursing (DON) identified the resident's medical record did not contain an assessment or care plan addressing the use of this indwelling catheter. The DON did find hospital records to support the use of the catheter, but this information was not carried forward to alert the staff as to the size of catheter to be used, the reason this catheter was needed, or the type of care to be provided to prevent complications. .",2014-11-01
10872,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,281,D,0,1,GPSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and a review of manufacturer's instructions for using a prescribed inhalation powder, the facility failed to assure medications were administered using appropriate techniques and in accordance with the manufacturer's instructions. Two (2) residents were observed receiving the [MEDICATION NAME] Diskus, and there were no attempts or instructions provided to rinse their mouths out with water and spit it out after this medication was inhaled. Failure to properly administer medications was observed for two (2) of ten (10) sampled residents. Resident identifiers: #26 and #28. Facility census: 100. Findings include: a) Resident #26 During medication pass on 06/09/09 at 9:30 a.m., the nurse was observed administering an [MEDICATION NAME] Diskus to this resident. The nurse prepared the inhaler by opening the container and clicking the button. The inhaler was then handed to the resident, who properly inhaled the medicated powder. The nurse then closed the container and left the room. The nurse did not offer the resident water to rinse out his mouth or provide instructions to the resident that he should rinse out his mouth. b) Resident #28 During medication pass on 06/09/09 at 10:03 a.m., the nurse was observed administering an [MEDICATION NAME] Diskus to this resident. The nurse prepared the inhaler by opening the container and clicking the button. The inhaler was then handed to the resident, who properly inhaled the medicated powder. The nurse then closed the container and left the room. The nurse did not offer the resident water to rinse out his mouth or provide instructions to the resident that he should rinse out his mouth. c) The nurse (Employee #28), when interviewed on 06/09/09 at 1:00 p.m., was made aware of the failure to prompt the residents to rinse their mouths following administration of the [MEDICATION NAME] Diskus. The nurse stated this was not done because these residents refused to rinse their mouths. The nurse was asked to provide documentation to reflect attempts by the facility to educate them on the proper procedures for administering this medication, as well as documentation of each resident's refusal to comply. The nurse could not provide evidence this had been recorded or that the physician had been made aware the residents were refusing to rinse their mouths after administration of the inhaler. d) Review manufacturer's instructions for the administration of [MEDICATION NAME] Diskus inhaler, found in the package insert, revealed the following a highlighted area, ""Remember: After each dose, rinse your mouth with water and spit the water out. Do not swallow."" .",2014-11-01
10873,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,329,D,0,1,GPSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to the drug regimen, of one (1) of twenty-eight (28) sampled residents in Stage II of the survey, was free of unnecessary medications ([MEDICATION NAME]) without adequate indications for use. This was true for one (1) of twenty-eight (28) residents in the Stage II sample. Resident identifier: #99. Facility census: 100. Findings include: a) Resident #99 Record review revealed a physician's telephone order, dated 05/31/09 at 5:00 p.m., instructing staff to administer the medication [MEDICATION NAME] 1 mg two (2) tabs to equal 2 mg by mouth ""now"" for Anxiety Disorder. ([MEDICATION NAME] is an anti-anxiety medication which can be very sedating and should be used cautiously in the elderly.) Further record review revealed the monthly recapitulation of physician orders [REDACTED]. Review of the nursing notes for 05/31/09 found no documented behavioral episodes to indicate this resident exhibited increased anxiety. Review of the May 2009 daily behavior tracking form, on which staff was to record when the targeted behavior of ""increased anxiety"" was exhibited, revealed no evidence that this resident had any behaviors to necessitating the administration of [MEDICATION NAME]. During an interview on 06/16/09 at 4:00 p.m., the director of nursing (DON) verified there was no evidence to justify the administration of this medication. The DON interviewed the nurse who called the physician and administered this medication, and she verified she had not recorded anything about the resident's behavior the evening she called the physician, because she was busy and forgot to record it. .",2014-11-01
10874,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,309,D,0,1,GPSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the medical record and staff interview, the facility failed to ensure staff implemented planned interventions with respect to the care and treatment of [REDACTED]. This resident was identified in her care plan as having mood and behavior problems, including resisting care and refusing medications. There was no evidence the facility attempted planned interventions to address refusal of medication, when the resident refused her [MEDICATION NAME] on twenty-eight (28) days of thirty-one (31) days in May 2009. This practice was evident for one (1) of twenty-eight (28) sampled residents in Stage II of the survey. Resident identifier: #99. Facility census: 100. Finding include: a) Resident #99 Medical record review revealed this resident had a physician's orders [REDACTED]. A review of the May 2009 Medication Administration Record [REDACTED]. There was no explanation recorded on the reverse side of the MAR indicated [REDACTED]. (See also citation at F514.) Review of the resident's care plan, established on 10/05/07, found: ""If the resident refuses her medication, staff need (sic) to try to calm her, talk in a calm voice, remain positive, and try medications at a different time to see if that helps. Try other redirections to help such as drinks, snacks etc."" There was no evidence in the medical record that these interventions were attempted. During an interview on 06/16/2009 at 10:15 a.m., the director of nursing (DON) identified this resident refused the [MEDICATION NAME] nasal spray and became combative at times. The DON was unable to find evidence to reflect any of the interventions established in Resident #99's care plan, to address refusal of medication, had attempted without success or that any discussion had occurred with the physician regarding possible discontinuation of this medication in lieu of an alternate treatment for [REDACTED]. .",2014-11-01
10875,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,249,C,0,1,GPSU11,"Based on staff interview and personnel file review, the facility failed to employ the services of a qualified professional to oversee the activities program. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #12. Facility census: 100. Findings include: a) Review of sampled personnel records, on 06/16/09 at approximately 10:00 a.m., revealed the facility's current activity director (Employee #12) did not have evidence to reflect she was qualified, by education or experience, to serve in this capacity. In an interview, Employee #12 reported she had completed a State approved training course which would have qualified her to perform the duties of an activity director; however, she could not locate any documents verifying course completion. The administrator indicated he was aware Employee #12 could not locate proof of her certification as an activity director. .",2014-11-01
10876,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2011-07-27,157,D,1,0,WXEM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the attending physician of an acute change in condition for one (1) of forty-six (46) Stage II sample residents. Resident #101 had treatment orders to assess her skin every shift and note any problem areas in the nurses notes. Nursing staff documented, on 07/01/11, the presence of a red raised area with a yellow center on the resident's lower left abdomen, but no further documentation was recorded in the nursing notes regarding the status of this alteration in skin integrity until 07/04/11, when the area was noted to have thick yellow exudate. Although a licensed practical nurse (LPN) documented having faxed information about this area to the on-call physician on 07/04/11, there was no evidence in the facility's fax book of this communication with the on-call physician, there was no evidence that any nursing staff communicated this information to the registered nurse (RN) on-call or to nurses on subsequent shifts, and there was no evidence that any nursing staff followed up with the resident's attending physician when no response was received from the on-call physician. No further documentation was found in the nursing notes about the abdominal wound from 07/04/11 until 07/08/11, when the resident was transferred to the hospital and admitted for treatment including surgical excision of a large abdominal mass. Resident identifier: #101. Facility census: 134. Findings include: a) Resident #101 Review of the July 2011 treatment administration record (TAR) revealed an order, dated 05/05/11, to assess the resident's skin and circulation every shift and note any problem areas in nursing notes. Each block on the TAR for all three (3) shifts from 07/01/11 through 07/08/11 was initialed by a nurse, indicating that a skin assessment had been completed on each shift. Review of nursing notes found an entry, dated 07/01/11 at 8:00 p.m., describing a red raised area with a yellow center and no drainage on the resident's lower left abdomen. The resident was [MEDICATION NAME] this time for a urinary tract infection and had previously been treated with another antibiotic (Z-Pak) from 06/16/11 through 06/20/11. Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/04/11 at 8:45 p.m., at which time an LPN (Employee #172) documented that she had faxed the on-call physician (who was covering during the absence of the attending physician) information regarding the presence of a ""red raised area, resembling a boil on lower left abdomen ... with occasional thick yellow exudate noticed"". Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/08/11 at 8:45 p.m., when a nurse recorded, ""See transfer sheet."" Review of the nursing transfer / discharge note, dated 07/08/11 at 8:45 p.m., revealed Resident #101 was transferred to the emergency room and subsequently admitted to a local hospital because of increased confusion and a large, painful, red area to the left abdomen. This reddened area measured 3 cm x 2 cm with a white center. A ""Body Check"" form, dated 07/08/11, described the left abdominal wound as a red area with a white center, warm, hard, and painful to touch. Review of an operative report from the hospital revealed a preoperative and postoperative [DIAGNOSES REDACTED]. An excision of a large mass on the anterior abdominal wall was performed on 07/11/11. Review of nursing notes, dated 07/11/11 at 10:15 p.m., found the resident returned to the facility by ambulance, was prescribed an antibiotic, was ordered to have a wound vac the following morning, and was to attend a follow-up appointment at the wound clinic on 07/25/11. During an interview on 07/26/11 at 11:20 a.m., the ward clerk (Employee #241) said faxes were filed in the fax book to show, if asked, that staff had sent notifications to the physician. She looked through the fax book and said there was no fax filed in the book of any communication to the on-call physician caring for Resident #101 on 07/04/11. When asked if the physician's response or outcome was always written on the fax in the book, she said, ""Not always."" During an interview with an RN supervisor (Employee #234) on 07/26/11 at 2:40 p.m., she said she would have expected the nurses to document the resident's skin condition each day after the redness on the abdomen was first discovered on 07/01/11. She agreed there was no fax on file related to the nurse notifying the on-call physician of the resident's abdominal wound with exudate. She said filing of the faxes in the book was not a policy - rather, it was a nursing measure to show proof that a fax had been sent - and that the unit secretary was responsible for filing them. She stated the nurse on 07/04/11 should have communicated to the next shift about the status of the resident's abdomen, followed up with the physician, and notified the RN on-call of the exudate. She stated their infection control program specifies the RN supervisor is to be notified when there is a wound with drainage. It was she (Employee #234) who was the RN on-call that day, and she confirmed she was not notified of the wound. She said a culture and sensitivity should have been done on the exudate and treatment should have been initiated at that time. During an interview with the administrator on 07/27/11 at 7:30 a.m., she said the nurse should have spoken with the physician about the drainage and should have inquired whether he wanted to order a culture. No further information was presented related to the absence of the fax in the book regarding communication the nurse had with the on-call physician about the wound on Resident #101's abdomen on 07/04/11, and no further information was presented related to having no follow-up communication with the attending physician or other nursing staff about the wound. During an interview with an LPN (Employee #176) on 07/27/11 at 9:40 a.m., she clarified that Resident #101's physician called with new orders for lab tests for the resident on 07/07/11, and that he did not say anything about Resident #101's abdomen during that telephone call. She further stated she knew nothing about a fax by Employee #172 to the on-call physician regarding the resident's abdomen, and she verified that information about the abdominal wound was not passed along to nursing staff on the subsequent shift. (See also citation at F309.) .",2014-11-01
10877,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2011-07-13,441,E,1,0,CG4E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, policy review, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe environment to help prevent the development and transmission of disease and infection. Seven (7) residents were physician-ordered to be in contact precautions or isolation, yet had no signage at the door indicating what type of personal protection for staff or visitors to use to prevent transmission of infectious organisms. For these seven (7) residents, there was no personal protective equipment readily available at the doors for staff or visitors to utilize prior to entering the residents' rooms. This was evident for seven (7) of eleven (11) sampled residents (#24, #43, #14, #81, #71, #37, and #17). Also, the facility failed to provide timely follow-up to determine when contact precautions could be discontinued, to ensure residents were not unnecessarily placed in isolation precautions for extended periods of time. This was evident for three (3) of eleven (11) sampled residents (#81, #71, and #17). Facility census: 89. Findings include: a) Residents #24, #43, #14, and #37 Observation, during the initial tour of the facility 07/11/11 beginning shortly after 10:30 a.m., revealed Residents #24, #43, #14, and #37 had light colored signs on their corridor doors directing visitors to see the nurse before entering. The signage provided no further directions, and no carts were found outside of these rooms to supply personal protective equipment (e.g., gloves, gowns, masks, etc.). In an interview on 07/11/11 at approximately 10:45 a.m., Employee #1 revealed she was doing audits of the isolation rooms at this time. She stated one (1) of the rooms had a cart available about two (2) weeks ago, but it had apparently been moved. She further stated the facility did not use signage with instructions about personal protective equipment for staff or visitors to use. Staff used ""focus sheets"" which identified the type of isolation precautions to be used for assigned residents, and visitors were expected to know to ask staff before they entered the rooms. She also reported that Resident #24 did not need to be in isolation anymore. Record review revealed Residents #24, #43, #14, and #37 each had physician orders [REDACTED]. Further record review revealed the care plans for Residents #24, #43, #14, and #37 each contained interventions referencing contact precautions and the use of proper signage and isolation carts. Observations, on 07/11/11 at 3:15 p.m., revealed Residents #43 and #14 now had carts at the door with personal protective equipment. Interviews with Employees #27, #106, and #1, on 07/11/11 at 5:00 p.m., revealed the facility did not use signage at the doors with directives for personal protective equipment, and that carts containing personal protective equipment were not necessary at isolation room doors, because staff had access to personal protective equipment. Observations, on 07/12/11 at 1:45 p.m., revealed Residents #43, #14, and #37 now had carts at the door with personal protective equipment. Review of facility's policy for MRDOs related to contact precautions (revised October 2009) revealed, at Item 8.: ""... c. Have supply of gowns and other PPE (personal protective equipment) readily available; ... f. Place facility-specific signs / stickers on the door and on the chart; g. Our facility's signage for notation of precautions is as follows: __________. ..."" (This space was left blank.) -- b) Residents #81, #71, and #17 Observations, during the initial tour of the facility on 07/11/11 beginning shortly after 10:30 a.m., revealed Residents #81, #71, and #17 had signs posted on their doors directing visitors to see the nurse before entering. Observations revealed none of the three (3) residents had signage at the entrance to their rooms with directives for staff or visitors to follow, and there were no carts outside their rooms to supply personal protective equipment. Record review revealed Resident #81 had physician orders [REDACTED].#71 had physician orders [REDACTED].#17 had physician orders [REDACTED]. Further record review revealed the care plans for Residents #81 and #17 each contained interventions referencing contact precautions and the use of proper signage and isolation carts. The care plan, dated 12/30/10, for Resident #71 stated to follow contact precautions. Interview with Employee #1, on 07/11/11 at approximately 10:45 a.m., revealed Resident #81 no longer needed isolation precautions. Observations, on 07/12/11 at 3:15 p.m., revealed Resident #17 now had a cart at the door with personal protective equipment. Review of care plans for Residents #81, #71, and #17 revealed each had contact precautions discontinued on 07/11/11. Interviews with Employee #1, #106, and #107, on 07/11/11 at 5:00 p.m., found that Residents #81, #71, and #17 had isolation precautions discontinued on 07/11/11. When asked why these residents had physician orders, care plans, and ""See Nurse"" signs at their doorways for such lengthy amounts of time, they reported that audits were being updated 07/10/11 (on the day this surveyor arrived). .",2014-11-01
10878,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2011-07-13,505,D,1,0,CG4E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to promptly notify the physician when an abnormal culture result and accompanying sensitivity report were obtained, so that prompt, appropriate action could be taken. This was evident for one (1) randomly sampled residents. Resident identifier: #46. Facility census: 89. Findings include: a) Resident #46 Record review revealed a culture and sensitivity report was faxed to the facility at 1:36 p.m. on 07/11/11. Review of this report revealed a culture of a right hip wound that was positive for two (2) organisms, one (1) of which was [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). Further record review revealed the culture slip was signed by the physician's assistant on 07/12/11, and on 07/12/11 at 6:30 a.m., Employee #1 noted that an isolation cart was outside the resident's room and a sign was posted on the resident's door; this occurred on 07/12/11, although the lab results were received by the facility on 07/11/11. During an interview with Employee #12 on 07/12/11 at 2:15 p.m., she stated the physician was not contacted about the abnormal lab result on 07/11/11, noting sometimes they did not get the lab result at their unit's fax machine. Instead, such reports may be transmitted to the fax machine in the front of the building. When asked, she said this resident was not in isolation yesterday but was put in isolation this morning with a cart at the door. During an interview with Employee #1 on 07/12/11 at 2:20 p.m., she said this resident was in a room by herself, because she had ESBL in the opposite hip wound which cleared. Since there was drainage and an odor from the other hip, they left her in isolation as a precaution, and a culture was completed. She had a isolation cart and a ""See Nurse"" sign at her door yesterday. When asked how they know if a physician is notified of lab results, she said the physician signs the slip or the nurse writes on the slip that he was contacted. She stated the physician's assistant signed the culture slip the morning of 07/12/11. During interviews with Employees #1, #106, and #107 on the late morning of 07/13/11, this information was shared with no further information obtained.",2014-11-01
10879,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,159,D,0,1,4I6911,"Based on staff interview and record review, the facility failed to obtain written authorization from the appropriate party prior to handling the personal funds for two (2) of twenty (20) residents in the sample. Resident identifiers: #10 and #98. Facility census: 111. Findings include: a) Resident #10 Review of the financial records for this resident showed the resident's medical power of attorney (MPOA) representative signed the authorization form to allow the facility to manage Resident #10's personal funds. This individual was not granted power of attorney by the resident to make financial decisions. b) Resident #98 The resident's trust fund authorization form was signed, on 12/20/08, by a family member who was not granted power of attorney by the resident to make financial decisions; this family member had also not been appointed by the court to serve as the resident's conservator. c) Both of these issues were discussed with the business office manager (Employee #53) on 12/08/09 and again on 12/09/09, who verified these individual did not have the authority to make financial decisions on behalf of the residents. .",2014-11-01
10880,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,246,D,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on two (2) sampled and two (2) random observations; resident, family, and staff interviews; and record review, the facility failed to: (a) provide furniture (a bed) that was the correct size for the resident; and (b) ensure assistance with feeding was given as needed and/or positioning devices were provided as required. This was evident for four (4) residents in the facility. Resident identifiers: #83, #24, #43, and #46. Facility census: 111. Findings include: a) Resident #83 Observation, at lunch on 12/08/09, found the resident in a bed which was not long enough for his height. The residents's wife was present and expressed concern regarding this issue. The resident's feet were touching the foot board of the bed while his head was at the top of the mattress, which was slightly raised up for eating. The bed was a new bed, as some furniture items had been replaced in the recent remodeling of the facility, but staff had never evaluated the need for a longer bed for this resident. This was discussed with the director of nursing (DON) on 12/09/09 and then the administrator shortly thereafter. On 12/10/09, observation found a new bed being assembled and put in the resident's room. b) Residents #24 and #45 1. Resident #24 At lunch (11:48 a.m.) on 12/08/09, this resident was randomly observed sitting in her bed with a special sippy cup attempting, to drink from the cup. Her lunch tray was on the overbed table with the food uncovered. The surveyor noted several staff members passing the room, but none offered to encourage the resident to eat her meal. At 12:20 p.m., a staff member (Employee #121) was summoned by the surveyor to the resident's room to see that the food was still uncovered and untouched. All this time, the resident was trying to get liquids from the special cup. Review of physician orders [REDACTED]. The minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/15/09, found the resident was independent in eating with set up help only. This MDS has been completed prior to the order of 10/12/09. The resident had experienced a weight loss and was ordered [MEDICATION NAME] and health shakes. Current care plan interventions regarding recent weight loss included administration of [MEDICATION NAME] and staff to encourage and monitor the resident's oral intake. 2. Resident #45 (Roommate of Resident #24) At lunch (11:48 a.m.) on 12/08/09, this resident was randomly observed lying in bed asleep with her food tray on the overbed table; the food was setting uncovered and untouched. Over a period of about thirty (30) minutes, observation found no assistance or encouragement offered by any staff. Employee #121 also was alerted to the fact this resident had received no staff assistance with feeding. The MDS with an ARD of 10/05/09 indicated the resident was independent in eating with set up help only. However, the current care plan stated staff was to encourage 50% to 75% of each meal daily for adequate intake. 3. These issues concerning Residents #24 and #45 were identified to Employee #121, who verified the trays were uncovered and attempted to resolve the problems. The residents had not received the encouragement and assistance as needed. c) Resident #46 During an interview conducted with Resident #46 on 12/10/09 at 9:45 a.m., observation found the resident had slid sideways in the bed with her right shoulder over the edge of the mattress. This alert and oriented resident was asked if she could reposition herself in the bed. It was noted that no side rails or other enabling devices were attached to the bed to assist the resident to reposition herself. The resident grasped the edge of the mattress with her left hand and tried to pull herself over. She was unable to do so. The resident stated that, if she had side rails, she could pull herself over, but she had been told the type of bed she was in could not utilize side rails. A review of the current care plan, with a goal date of 01/29/10, related to bed mobility found the following language, ""Encourage use of 1/2 siderails x 2 for bed mobility."" The facility failed to accommodate this resident's need for assistive equipment to enable her to reposition herself in bed. .",2014-11-01
10881,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,279,D,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to develop comprehensive care plans with measurable goals to meet each resident's assessed needs. This was true for two (2) of twenty (20) sampled residents. The care plan of Resident #63 did not adequately address her needs related to her arteriovenous access (AV shunt), and Resident #17's care plan did not address [MEDICAL CONDITION] for which the resident was receiving an hypnotic. Facility census: 111. Findings include: a) Resident #63 Resident #63 was observed in her room at 10:30 a.m. on 12/09/09. This alert resident reported she was admitted to the facility for rehabilitation and wound care. The left upper arm was observed to have an AV shunt for [MEDICAL TREATMENT]. Resident #63's medical record, when reviewed on 12/09/09 at 1:00 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] for rehabilitation and wound care after a recent hospitalization for an above-the-knee amputation of the right leg. The resident had end stage [MEDICAL CONDITION] and required outpatient [MEDICAL TREATMENT] three (3) times a week. Review of the comprehensive care plan, dated 11/02/09, found no specific guidance to staff, directing them to not take blood pressures or venipunctures from the left arm. The director of nurses (DON - Employee #118), when interviewed on 12/10/09 at 10:15 a.m., confirmed these intervention should have been listed on the care plan. b) Resident #17 The medical record of Resident #17, when reviewed on 12/09/09, disclosed this [AGE] year old had been admitted to the facility on [DATE]. Shortly after admission, the resident had been hospitalized and upon return to the facility on [DATE]. The resident had a physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. The current [DIAGNOSES REDACTED]. The care plan established for this resident was reviewed. The plan, last updated on 12/02/09, contained no mention of the problem of [MEDICAL CONDITION] and no mention of established methods to address the problem other than medication. The DON was interviewed on 12/09/09 at 3:30 p.m., as to a care plan for this resident related to the problem of [MEDICAL CONDITION] and inability to maintain a sleep pattern for greater than two (2) hours. The DON, after review of the current care plan, confirmed the problem of [MEDICAL CONDITION] and non-pharmacologic interventions to address the problem were not included in the resident's current care plan. .",2014-11-01
10882,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,241,D,0,1,4I6911,"Based on observation, staff interview, medical record review, and resident interview, the facility failed to provide care to residents in an environment that maintained or enhanced each resident's dignity. This deficient practice affected three (3) of twenty (20) sampled residents in need of personal grooming and had the potential to affect all residents who wished to utilize the rest room located near the front lobby. Resident identifiers: #46, #59, and #2. Facility census: 111. Findings include: a) Rest Room During random observations of the resident environment during the initial tour of the facility on 12/07/09 at 4:40 p.m., a sign was noted to be posted on the rest room door near the front lobby. The clearly visible sign stated, ""Notice: Restroom is for visitors and staff only. Residents please do not use (sic) thank you."" An interview with the director of nursing (DON - Employee #113) elicited no justification as to the reason a restroom located in the residents' home would be off limits to them. b) Resident #46 During an interview with this alert and oriented female resident on 12/10/09 at 9:45 a.m., observation found she had numerous long hairs growing from her chin. When asked how she felt about having the chin hairs, she stated she did not like them and wanted them cut off. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 11/01/09, in Section G1j, found the resident was totally dependent on staff for personal hygiene. c) Resident #59 Random observation, on the afternoon of 12/08/09, noted numerous long chin hairs present on the resident. Review of the MDS, with an ARD of 11/13/09, in Section G1j, found that the resident required total assistance with personal hygiene. d) Resident #2 During the initial tour of the facility on 12/07/09 at 2:15 p.m., observation found Resident #17 in her room in her wheelchair. During conversation with this resident, it was noted she had several long hairs protruding from her chin and the side of her upper lip. When questioned as to how much assistance she needed to bath, clean her teeth, etc., the resident stated she could do a little, but the staff needed to help her complete most of her hygiene needs. .",2014-11-01
10883,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,309,D,0,1,4I6911,"**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 (20) residents reviewed, to provide care that would assure the highest practicable well-being of the resident and as ordered by the physician. The facility failed to obtain a stool [MEDICATION NAME] when ordered by the resident's physician. Resident identifier: #17. Facility census: 111. Findings include: a) Resident #17 When reviewed on 12/09/09, the resident's medical record described the resident as being 96-years old with numerous medical [DIAGNOSES REDACTED]. The record contained a physician's orders [REDACTED]. This order did not clarify how many times the physician wanted the test performed. On 11/23/09, another order was obtained, directing staff to [MEDICATION NAME] stool three (3) times. The resident's treatment record for the month of November 2009 contained an entry on 11/18/09 which stated ""[MEDICATION NAME] stools x 3"" with areas designated for the initials of the staff member completing the tests. There were no initials recorded in those areas to indicate the tests had been completed. The December 2009 treatment record, when reviewed, found entries related to [MEDICATION NAME] of stools. Several initials were noted in the designated areas on this record, but all were either illegible or circled to indicate the test had not been completed. The facility's director of nurses (DON - Employee #118), when interviewed on 12/09/09 at 3:30 p.m. and following review of the resident's record, confirmed the [MEDICATION NAME] had not been completed. The tests were completed the following day. .",2014-11-01
10884,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,156,E,0,1,4I6911,"Based on record review and staff interview, the facility failed to provide a written notice to residents who were no longer eligible for Medicare skilled services that stated the reason they no longer qualified, as required in the Medicare Skilled Nursing Manual at ""Notifying Patient of Noncoverage SNF-356.1"". This practice was observed when reviewing a sample of three (3) such letters that had been provided to residents or their responsible parties in the previous three (3) months. The practice had the potential to affect all residents of the facility who had been, or would be in the future, determined to be ineligible for Medicare-covered skilled services. Resident identifiers: #35, #54, and #37. Facility census: 111. Findings include: a) Residents #35, #54, and #37 The Notice of Medicare Provider Non-Coverage, as provided by the facility for Residents #35, #54, and #37, was requested for review on 12/09/09. Review of these notices disclosed, on the third page of the document associated with Item #4, the document stated: ""Because: Not requiring a skilled service."" Each of the notices had the same statement and made no explanation specific to the individual resident's discontinuation of Medicare-covered services. The facility employee responsible for the distribution of these notices (Employee #53), when interviewed on 12/09/09 at 2:45 p.m., confirmed this was the notice provided to all residents of the facility at the time they were determined by the facility to no longer qualify for Medicare-covered skilled services. This employee further confirmed the information was not individualized for each resident and situation. .",2014-11-01
10885,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,329,E,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the drug regimens for four (4) of twenty (20) residents reviewed were free of unnecessary drugs. One (1) resident was receiving a medication to induce sleep with no documented episodes of [MEDICAL CONDITION] and was also receiving an antianxiety medication ordered to be given on an ""as needed"" basis with no documentation of the need or of the efficacy of the medication. Another resident was receiving a medication for the control of nausea and for pain on an ""as needed"" basis with no documentation of the need or of the efficacy of the medication. Another resident was receiving a antianxiety medication with no documentation of the need or the monitoring of the efficacy of the medication. A fourth resident was also receiving a medication for the control of nausea with no documentation of the need and no monitoring of the efficacy of the medication. Resident identifiers: #17, #63, #112, and #38. Facility census: 111. Findings include: a) Resident #17 1. The medical record of Resident #17, when reviewed on 12/09/09, disclosed this [AGE] year old had been admitted to the facility on [DATE]. Shortly after admission, the resident had been hospitalized and upon return to the facility on [DATE]. The resident had a physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. The current [DIAGNOSES REDACTED]. The care plan established for this resident was reviewed. The plan, last updated on 12/02/09, contained no mention of the problem of [MEDICAL CONDITION] and no mention of established methods to address the problem other than medication. Further review of the record disclosed no evidence the resident was suffering from [MEDICAL CONDITION]. The resident's medical record contained two (2) minimum data set (MDS) assessments. One (1) was based on an assessment reference date (ARD) of 08/17/09, and the other on an ARD of 09/12/09. The section of these documents that makes reference to [MEDICAL CONDITION] is Item E1k (Indicators of depression, anxiety, sad mood - [MEDICAL CONDITION] / change in usual sleep pattern). On both of the MDS assessments, the entry for this section was ""0"", indicating the resident had not experienced this indicator. Review of the nursing notes disclosed no mention of the resident's inability to sleep. The facility's director of nurses (DON - Employee #113), when interviewed on 12/08/09 at 11:50 a.m. and asked to review the record for evidence of [MEDICAL CONDITION], confirmed there was no documented evidence of [MEDICAL CONDITION] associated with this resident. 2. The resident also had a physician's orders [REDACTED]. Documentation on the resident's November 2009 medication administration record (MAR) indicated the resident received [MEDICATION NAME] twenty-one (21) times in that month. On none of these occasions did facility staff document the sign or symptom necessitating the administration of the medication, nor did staff record the efficacy of the medication following its administration. When interviewed on 12/8/09 at 11:50 a.m., the DON confirmed facility staff had not documented the need for the medication prior to its administration or the efficacy of the medication following the administration. b) Resident #63 Resident #63's medical record, when reviewed on 12/09/09 at 10:45 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] with multiple pressure ulcers. The physician had ordered ""[MEDICATION NAME] 10/500 mg po (by mouth) q4h (every four hours) prn (as needed) for pain"" on 10/16/09. Review of the November 2009 MAR revealed the resident received the pain medication on 11/03/09, 11/07/09, 11/12/09, 11/13/09, 11/17/09, 11/18/09, 11/19/09, 11/23/09, and 11/24/09. On 10/16/09, the physician ordered: ""[MEDICATION NAME] 25 mg po prn q6hrs (every six hours) prn for nausea / vomiting."" The resident received [MEDICATION NAME] 25 mg on 11/02/09, 11/16/09, 11/17/09, and 11/18/09. Review of the MAR and nursing notes revealed staff failed to record the resident's response to the pain and antiemetic medications for the above dates. The DON, when interviewed on 12/10/09 at 10:15 a.m., did not provide any written evidence to reflect that staff monitored the resident's response to the pain and antiemetic medication. c) Resident #112 Resident #112's medical record, when reviewed on 12/10/09 at 8:15 a.m., revealed the resident's physician had ordered: ""[MEDICATION NAME] 0.5 mg q6h po PRN anxiety."" Review of the September 2009 MAR revealed the resident received [MEDICATION NAME] on 09/30/09. Review of the MAR and nursing notes for September 2009 revealed staff failed to record the resident's response to the antianxiety medication for 09/30/09. The DON, when interviewed on 12/10/09 at 10:15 a.m., did not provide any written evidence to reflect that staff monitored the resident's response to the antianxiety medication. d) Resident #38 Resident #38's medical record , when reviewed on 12/10/09 at 9:00 a.m., revealed an [AGE] year old female who was admitted to the facility on [DATE]. On 10/31/09, the physician ordered: ""[MEDICATION NAME] 12.5 mg po q6h prn d/t (due to) N/V (nausea / vomiting)."" Review of the November 2009 MAR revealed the resident received [MEDICATION NAME] on 11/02/09. Review of the MAR and nursing notes for November 2009 revealed staff failed to record the resident's response to the antiemetic medication for this date. The DON, when interviewed on 12/10/09 at 10:15 a.m., did not provide any written evidence to reflect that staff monitored the resident's response to the antiemetic medication. .",2014-11-01
10886,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,314,D,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility staff interview, the facility failed to assure that care and services were provided in a timely manner to promote healing of pressure ulcers. This deficient practice affected two (2) of twenty (20) sampled residents. Resident identifiers: #38 and #112. Facility census: 111. Findings include: a) Resident #38 Resident #38's medical record, when reviewed on 12/09/09 at 1:45 p.m., revealed an [AGE] year old female who was admitted to the facility on [DATE], for rehabilitation services after a recent fall with a fracture to the left femur. The resident's admission nursing assessment, dated 10/28/09, reported the resident had a Stage II pressure ulcer on her coccyx upon admission. Review of the admission orders [REDACTED]. On 11/01/09, the physician ordered: ""[MEDICATION NAME] to R (right) fold coccyx area Stage II, change Q (every) 7 days, check Q shift, Change PRN (as needed), re-evaluate 21 days."" Documentation on a ""Condition Change Form"", dated 11/06/09, stated: ""D/C (discontinue) [MEDICATION NAME] Dressing Stg. II coccyx wound resolved."" Review of the facility's policy on wound care titled ""The War on Wounds Program"" (dated January 2008) found in Section 4: ""Notify the physician and responsible party and collaborate on a treatment order."" There was no evidence in the medical record to indicate the physician was notified of the resident's Stage II pressure ulcer until 11/01/09. The director of nurses (DON - Employee #118), when interviewed on 12/08/09 at 10:45 a.m., acknowledged treatment to the resident's coccyx pressure area was not initiated until 11/01/09, four (4) days after her admission to the facility. b) Resident #112 Resident #112's medical record, when reviewed on 12/10/09 at 8:00 a.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment revealed the resident had two (2) Stage II pressure ulcers on the buttocks. Review of the admission physician orders, dated 08/07/09, revealed the physician had not ordered any treatment to the Stage II pressure areas. A facility form titled ""Incident / Accident Report Quality Concerns Document"", dated 08/10/09, stated: ""CNA (certified nursing assistant) reported dressing to buttocks dated 8/6/09. Found dressing from hospital dated 8/6/09. Removed dressing (sic) found Stage II to L (left) & R (right) buttocks. Complete body audit done (sic) see above."" On 08/10/09, the physician ordered: ""Clean Stage II on buttocks with NSS, pat dry, cover with [MEDICATION NAME] Q 7 days and PRN, check placement Q shift."" Review of the facility's policy on wound care titled ""The War on Wounds Program"" (dated January 2008) found in Section 4: ""Notify the physician and responsible party and collaborate on a treatment order."" There was no evidence in the medical record to indicate the physician was notified of the resident's Stage II pressure ulcers until 08/10/09. The DON, when interviewed on 12/10/09 at 10:15 a.m., acknowledged the resident did not receive treatment to the pressure ulcers for three (3) days. .",2014-11-01
10887,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,514,C,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medical records were accurate and legible. This was true for four (4) of twenty (20) sampled residents. The facility's process for recording physician telephone orders failed to ensure legible writing for future review and reference. The facility's utilization of a carbon copy method to record physician telephone orders resulted in illegible orders until such time as the physician signed the original top portion and the signed orders were placed in the chart. This practice has the potential to affect all residents whose physician may phone in orders. The facility also failed to ensure physician orders [REDACTED]. Resident identifiers: #38, #63, #98, and #110. Facility census: 110. Findings include: a) Resident #38 Resident #38's medical record, when reviewed on 12/08/09 at 9:00 a.m., revealed a physician's telephone order dated 12/07/09, which was illegible. Review of the monthly recapitulation (recap) of physician orders [REDACTED]."" The December 2009 Medication Administration Record [REDACTED]. po q6hrs d/t (due to) anxiety."" In an interview on 12/08/09 at 10:45 a.m., the director of nurse (DON - Employee #118) acknowledged the physician's orders [REDACTED]. The DON stated there was a ""transcription error"" and the physician will write a new order to clarify. b) Resident #63 Resident #63's medical record, when reviewed on 12/10/09 at 9:45 a.m., revealed the physician's telephone orders for 12/02/09 and 12/07/09 were illegible. c) Resident #98 Resident #98's medical record, when reviewed on 12/10/09 at 10:00 a.m., revealed the physician's telephone order for 12/09/09 was illegible. d) Resident #110 Resident #110's medical record, when reviewed on 12/10/09 at 9:45 a.m., revealed the physician's orders [REDACTED]. e) The DON, when interviewed on 12/10/09 at 10:00 a.m., acknowledged the above physician's telephone orders were illegible and stated the facility plans to use a different form for recording them in the future.",2014-11-01
10888,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,323,E,0,1,4I6911,"Based on observation, inspection of mechanical lift pads, staff interview, medical record review, and resident interview, the facility failed to assure staff members refrained from utilizing defective lift pads designed to assist in the transfer of dependent residents by mechanical lifts. The facility also failed to assure appropriate numbers of staff members, as assessed by the interdisciplinary team, assisted in transferring residents by mechanical lift. This deficient practice affected one (1) of twenty (20) sampled residents and had the potential to affect more than an isolated number of residents who required transfer by use of mechanical lifts. Resident identifier: #46. Facility census: 111. Findings include: a) Resident #46 During random observations of the facility on 12/07/09 at 5:00 p.m., it was noted that Employee #52 was exiting Resident #46's room after transferring her with a sit-to-stand mechanical lift. Further observation noted the lift pad utilized to transfer the resident displayed a rip in the seam measuring approximately 6 inches in length with frayed edges. An interview with Employee #52 following the observation revealed she had not noticed the lift pad was torn prior to utilizing it to transfer the resident. She agreed an accident could have occurred due to the poor condition of the lift pad. Review of Resident #46's medical record found a minimum data set assessment (MDS) with an assessment reference date (ARD) of 11/01/09. Review of this MDS revealed the facility documented the resident was 65 inches tall and weighed 251 pounds. Further review of the MDS found the facility determined the resident was totally dependent on two (2) or more staff members for transfers. Review of the current care plan, with a goal date of 01/29/10, found the interdisciplinary team determined the resident required the total assistance of two (2) staff members for bed mobility and transfers. Review of the ""Resident Functional Performance Record"" found that staff members recorded utilizing the assistance of only one (1) staff member when transferring the resident on 12/03/09, 12/04/09, 12/06/09, 12/07/09, and 12/08/09. An interview with this alert and oriented resident, on 12/10/09 at 9:45 a.m., confirmed that only one (1) staff member assisted in transferring the resident at times. .",2014-11-01
10889,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,166,D,1,0,LRYJ11,". Based on observation, staff interview, review of the facility's grievance / concern records and self-reported allegations of abuse / neglect, and record review, the facility failed to make prompt efforts to resolve grievances reported by a family member on behalf of one (1) of six (6) sampled residents. A family member requested that Resident #36 be taken to the dining room for all meals. The family had visited the facility and found the resident was not taken to the dining room. This concern was investigated and validated by the facility, and staff instructed to take the resident to the dining room. Review of the facility's complaint records found the family then came in less than one (1) week later and had filed the same grievance. The facility again investigated this and recorded as a resolution: ""Resident will be taken to the dining room for all meals. Family pleased with the outcome."" During an initial tour of the facility on when dinner was served on 07/18/11, observation found Resident #36 in the bed and being fed her dinner; she had not been taken to the dining room. Resident identifier: #36. Facility census: 113. Findings include: a) Resident #36 During the initial tour of the facility at 5:00 p.m. on 07/18/11, observation found Resident #36 in bed in her room. She was awake, mumbled words that could not be comprehended, and smiled when this surveyor spoke to her. After completing the initial tour of the facility, the surveyor went back down this resident's hall found Resident #36 was still in bed. Her evening meal tray was sitting beside her TV on her bedside table at 5:30 p.m. with the lid on it and plastic wrap covering the drinks and fruit. Employee #107 (a nurse aide) came into the resident's room, moved the tray over to the bed, sat down beside the resident, and began to feed her. The resident was fed and did not perform any part of the eating tasks herself. The surveyor questioned Employee #107 at 6:00 p.m. on 07/18/11, about the resident eating in bed. Employee #106 stated she does not always have this resident on her assignment, but sometimes she does. She stated this resident eats in her room sometimes, and sometimes she eats in the dining room. Review of the facility's records of self-reported allegations of abuse / neglect found this resident's daughter stated her mother was not taken to the dining for breakfast on 06/29/11. The facility reported this as an allegation of neglect, investigated the incident, and determined the allegation was substantiated, as the resident was not taken to the dining room. Corrective action by the facility stated: ""All staff in-serviced on if residents are willing to go to the dining room they must go. This includes residents assisted with their meals."" A mandatory in-service was conducted and this was discussed with staff. Review of the facility's grievance / concern records found that, seven (7) days later (on 07/06/11), Resident #36's daughter filed a grievance stating she wanted the resident taken to the dining room for all meals. The daughter had come in for breakfast, found the resident was not in the dining room, and stated that if she had not come in, staff would not have taken her. According to documentation on the concern form, a care plan meeting was held, and this concern was discussed. Additional documentation on the concern form stated: ""The resident will be taken to the dining room for all meals including breakfast. Tray will be delivered directly to the dining room. Will be placed on 24 hour report to verify follow through."" The person completing the form noted this concern was resolved, the resident will be taken to the dining room for all meals, and the family was pleased with the outcome. Review of the resident's current care plan found the following intervention: ""Meals in the dining room when appropriate."" She also had an intervention that stated: ""Meals in dining room most days and meals."" The director of nursing (DON - Employee #82) was questioned about this issue at 2:00 p.m. on 07/19/11. When she was made aware that Resident #36 was observed eating dinner in bed in her room on the prior evening and that she was not in the dining room, the DON stated the resident was sometimes hard to wake up and staff could not transfer her safely. According to the DON, Resident #36 was a large lady and required the assistance of two (2) staff members for transfers; she can stand and pivot but at times, but staff cannot get her to do that because she refuses to get up, and when she is having these type of issues, the staff leaves her in bed and feeds her there. When asked for documentation to verify this, the DON was unable to produce this. She agreed the complaint resolution stated the resident would receive ""all meals in the dining room"" and, if this was not done, the facility needed to record the reason or communicate this with the family. .",2014-11-01
10890,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,203,D,1,0,LRYJ11,". Based on record review and staff interview, the facility failed to complete the Notice of Transfer or Discharge form to include the reason for a resident's transfer or discharge for one (1) of six (6) sampled residents. This section was left blank on the form completed for Resident #6 on two (2) separate occasions, with no reason given for a transfer that occurred on 07/07/11 and another transfer that occurred on 07/08/11. Resident identifier: #6. Facility census: 113. Findings include: a) Resident #6 Record review revealed a nursing note, entered at 2:30 p.m. on 07/07/11, stating: ""Resident hit another resident. Called MD (medical doctor) and RP (responsible party). Resident sent to hospital (named the hospital) ER (emergency room ) for eval (evaluation)."" The Notice of Transfer or Discharge form, when reviewed, was left blank where the facility was to specify the ""reason"" for the transfer or discharge. A late entry note indicated this resident returned from the hospital at 8:15 p.m. on 07/07/11. According to the medical record, the resident then sustained a fall and was sent back to the hospital at 11:30 p.m. on 07/08/11. Another Notice of Transfer or Discharge form was completed and, again, no reason for the transfer was recorded. The director of nursing (DON - Employee #82) verified the reason for transfer had not been recorded as required on either of these notices. .",2014-11-01
10891,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,280,D,1,0,LRYJ11,". Based on observation, staff interview, review of the facility's grievance / concern records and self-reported allegations of abuse / neglect, and record review, the facility failed to revise the care plan of one (6) of six (6) sampled residents to reflect changes in care. The facility had a care plan meeting during which staff agreed to ensure Resident #36 would be taken to the dining room for every meal. The care plan was not revised to reflect this change as had been discussed in the care plan meeting. Resident identifier: #36. Facility census: 113. Findings include: a) Resident # 36 During the initial tour of the facility at 5:00 p.m. on 07/18/11, observation found Resident #36 in bed in her room. She was awake, mumbled words that could not be comprehended, and smiled when this surveyor spoke to her. After completing the initial tour of the facility, the surveyor went back down this resident's hall found Resident #36 was still in bed. Her evening meal tray was sitting beside her TV on her bedside table at 5:30 p.m. with the lid on it and plastic wrap covering the drinks and fruit. Employee #107 (a nurse aide) came into the resident's room, moved the tray over to the bed, sat down beside the resident, and began to feed her. The resident was fed and did not perform any part of the eating tasks herself. The surveyor questioned Employee #107 at 6:00 p.m. on 07/18/11, about the resident eating in bed. Employee #106 stated she does not always have this resident on her assignment, but sometimes she does. She stated this resident eats in her room sometimes, and sometimes she eats in the dining room. Review of the facility's records of self-reported allegations of abuse / neglect found this resident's daughter stated her mother was not taken to the dining for breakfast on 06/29/11. The facility reported this as an allegation of neglect, investigated the incident, and determined the allegation was substantiated, as the resident was not taken to the dining room. Corrective action by the facility stated: ""All staff in-serviced on if residents are willing to go to the dining room they must go. This includes residents assisted with their meals."" A mandatory in-service was conducted and this was discussed with staff. Review of the facility's grievance / concern records found that, seven (7) days later (on 07/06/11), Resident #36's daughter filed a grievance stating she wanted the resident taken to the dining room for all meals. The daughter had come in for breakfast, found the resident was not in the dining room, and stated that if she had not come in, staff would not have taken her. According to documentation on the concern form, a care plan meeting was held, and this concern was discussed. Additional documentation on the concern form stated: ""The resident will be taken to the dining room for all meals including breakfast. Tray will be delivered directly to the dining room. Will be placed on 24 hour report to verify follow through."" The person completing the form noted this concern was resolved, the resident will be taken to the dining room for all meals, and the family was pleased with the outcome. Review of the resident's current care plan found the following intervention: ""Meals in the dining room when appropriate."" She also had an intervention that stated: ""Meals in dining room most days and meals."" The director of nursing (DON - Employee #82) was questioned about this issue at 2:00 p.m. on 07/19/11. She confirmed that the resident's care plan was not revised to reflect the discussion that had occurred during the care conference held with the family. .",2014-11-01
10892,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,514,D,1,0,LRYJ11,". Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately documented for one (1) of six (6) sampled residents. The documentation in the medical record of Resident #6 was not thorough and complete when describing the circumstances during which this resident struck another resident. The documentation did not include the interventions taken by the facility staff to assure this resident was and other residents were safe. Resident identifier: #6. Facility census: #113. Findings include: a) Resident #6 1. Record review revealed nursing notes, dated 07/07/11 at 2:30 p.m., stating: ""Resident hit another resident. Called MD (medical doctor) and RP (responsible party). Resident sent to the hospital ER (emergency room ) for eval (evaluation)."" The details of this occurrence were not recorded. The location of the residents when this occurred was not recorded, nor were any efforts made by staff in an attempt to redirect her. The note simply stated she was sent to the hospital for an evaluation. There was no entry in the record to note the resident's return to the facility later that evening due to lack of beds on the psychiatric unit. -- 2. In an interview at 1:00 p.m. on 07/20/11, the director of nursing (DON - Employee #82) reported Resident #6 had been transferred to the hospital for evaluation by the psychiatric unit for possible admission there. The hospital did not have any beds open on that unit, and the resident was returned to the facility. Upon the resident's return to the facility, the receiving nurse was instructed to provide one-on-one supervision until a bed became available. -- 3. The next entry in the nursing notes was recorded at 12:00 a.m. on 07/08/11, stating: ""This nurse received a phone call at approx 8:30 ish stating this resident needed to be one on one. The nurse gave order to evening shift aid. This nurse went to lunch @ (at) about 11p. While in the break room aid reported that this resident had fallen. Once reported back on floor, this nurse noted resident on floor with laceration to to forehead with bleeding. Resident was combative kicking and hitting as nursing staff was trying to apply bandage to head to stop/control bleeding. 911 was called. Family notified, Resident fell @ about 11:35 ish. Ambulance arrived at 11:50 ish. Resident out of facility @ 12:00 a.m."" This entry was not written in accordance with the accepted professional standards and practices. The times were not specific as to when these events occurred, and there was a period of approximately four (4) hours combined into a single note. There was no documentation to reflect the resident received the one-on-one supervision from the time she returned from the hospital or that she had been in a deep / comatose sleep since arriving back to the facility from the emergency room (as was identified in the facility's internal investigation notes). The DON, when interviewed at 1:15 p.m. on 07/20/11 about the information in this medical record, verified this nursing note failed to document what services and interventions staff was providing to her (one-on-one supervision), her response to those services over a 4-hour period of time, or the plan to send her back to the hospital as soon as a bed became available on the psychiatric unit.",2014-11-01
10893,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,253,E,0,1,BY0111,". Based on observations and staff interviews, the facility failed to provide housekeeping and/or maintenance services necessary to maintain a sanitary, comfortable, and orderly interior. The walls and/or furniture in many residents' rooms were in disrepair, rendering the surfaces unable to be effectively cleaned / sanitized and giving the interior a disorderly appearance. This was evident for at least fourteen (14) of fifteen (15) rooms in which sampled residents resided. Room numbers are listed in the findings below. Facility census: 147. Findings include: a) On 01/26/10, observations revealed the following concerns: - Room 110 - Nightstands and dressers banged up and scratched - Room 112 - Scuff marks on walls and dressers banged up - Room 114 - Big place at head of bed on wall that needs repaired, scratches on nightstands - Room 121 - Nightstand scratched and banged up - Room 123 - Nightstand scuffed up and scratched - Room 129 - Wall along the left side by first bed all scratched and scuffed up - Room 135 - Wall at head of beds scratched, nightstands banged and scuffed up. - Room 203 - Chest of drawers was scratched - Room 207 - Dresser scratched, wall near bathroom by bed close to door banged and scratched up - Room 215 - Wall at head of bed all banged up where trapeze bar attachment fits on bed, wall and closet doors all scuffed up badly - Room 217 - Chest and wall scuffed up - Room 223 - Spot near heater/air conditioner unit that needs repaired. - Room 229 - Chest of drawers banged up, place on ceiling above bed by window needs replaced / repaired This was shared with the administrator on 01/27/10 at 2:30 p.m., and with the environmental director at 3:00 p.m. the same afternoon. Neither had any further questions regarding the findings at that time. .",2014-11-01
10894,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,281,D,0,1,BY0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation during medication administration, record review, staff interview, and review of the Encyclopedia of Nursing & Allied Health / Administration of Medication, the facility failed to ensure one (1) of forty-one (41) Stage II sampled residents received services to meet professional standards of care. A resident received the incorrect dose of [MEDICATION NAME]. Resident identifier: #222. Facility census: 147. Findings include: a) Resident #222 Observation, during medication pass on 01/19/10 at 8:20 a.m., found the licensed practical nurse (LPN - Employee #8) administered to Resident #222 one (1) 5 mg tablet of [MEDICATION NAME]. Review of the medical record, on 01/19/10 at 9:30 a.m., revealed a current physician's orders [REDACTED]. When interviewed on 01/19/10 at 1:30 p.m., Employee #8 acknowledged the resident only received 5 mg of [MEDICATION NAME]. The LPN reported she notified the physician, and the resident was given the additional 10 mg that afternoon. According to the Encyclopedia of Nursing & Allied Health / Administration of Medication (web page http://www.enotes.com/nursing-encyclopedia/administration): ""Right dose. The formula for this calculation can be applied to many situations: dose ordered / dose on hand ? amount on hand = amount to administer."" .",2014-11-01
10895,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,278,D,0,1,BY0111,". Based on observation, record review, and staff interview, the facility failed to ensure the minimum data set assessment (MDS) was accurate for one (1) of forty-one (41) Stage II sampled residents. The MDS was inaccurately coded for a resident with bilateral knee contractures. Resident identifier: #28. Facility census:147. Findings include: a) Resident #28 Observation, in the physical therapy department on 01/26/10 at 3:00 p.m., found Resident #28 sitting in her wheelchair. Her knees were in bent positions. The physical therapist (Employee #61) demonstrated the resident's limited movement of her knee joints. The physical therapist, when interviewed on 01/27/10 at 2:10 p.m., reported Resident #28 had bilateral knee contractures. The medical record, when reviewed on 01/27/10 at 2:30 p.m., revealed the last two (2) quarterly MDS assessments, with assessment reference dates of 10/21/09 and 01/13/10 respectively, reported the resident did not have any contractures. In an interview on 01/27/10 at 2:50 p.m., the MDS coordinator (Employee #38) acknowledged the above-mentioned quarterly MDS assessments were inaccurate. .",2014-11-01
10896,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,329,D,0,1,BY0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the Lexi-Comp Drug Information Handbook, and staff interview, the facility failed to ensure the drug regimens for two (2) of forty-one (41) Stage II sampled residents were free of unnecessary drugs when used for excessive duration and/or in excessive dose (duplicate therapy). Resident #86 had been receiving [MEDICATION NAME] 5 mg three (3) times a day (TID) since 11/21/08 with no recommended dose reductions or documentation of the benefits versus risks of continued long term use. According to the Lexi-Comp Drug Information Handbook review, [MEDICATION NAME] is intended for short term use only (not more than seven (7) days) and should be used with caution in the elderly due to its high [MEDICATION NAME] effects. The side effects of [MEDICATION NAME] include hallucinations, behavioral changes, constipation, skin changes, dry mouth and lethargy. Medical record review revealed this resident had been experiencing behavioral problems (such as repetitive use of the call light and requests for staff help / attention, continuous yelling, aggression toward staff and other residents, and hallucinations), all of which were potential side effects of [MEDICATION NAME] use. Resident #166 had been receiving [MEDICATION NAME] 60 mg since January 2009 for depression and [MEDICATION NAME] 15 mg since 11/19/08 for depression with no attempts at a drug reduction. The use of two (2) or more antidepressants elevates the risk of side effects, and there was no evidence the physician documented the expected benefits that may outweigh the risks for this duplicate therapy. Resident identifiers: #86 and #166. Facility census: 147. Findings include: a) Resident #86 Medical record review, on 01/25/10, disclosed this [AGE] year old female resident had been receiving [MEDICATION NAME] 5 mg TID since 11/21/08 for a [DIAGNOSES REDACTED]. According to the Lexi-Comp Drug Information Handbook, [MEDICATION NAME] is intended for short term use only (not more than two (2) to three (3) weeks) and should be used with caution in the elderly due to its high [MEDICATION NAME] effects. The side effects of [MEDICATION NAME] include hallucinations, behavioral changes, constipation, skin changes, dry mouth, and lethargy. Medical record review, including a review of nursing notes from 09/08/09 to 01/24/10, found this resident had been experiencing behavioral problems such as repetitive use of the call light, repetitive requests for staff help / attention, continuous yelling, aggression toward staff and other residents, and hallucinations, all of which were potential adverse drug reactions. Review of physician's progress notes found no documentation indicating the long term use of [MEDICATION NAME] had been monitored and the benefits versus risks of the continued use of this drug had been documented. Interview with the director of care delivery (Employee #47), on 01/27/01, at 11:00 a.m., revealed the physician had been using the [MEDICATION NAME] long term for reasons other than relief of muscle spasms. Employee #47 also confirmed the physician had not made any documentation of the benefits versus risks of using the [MEDICATION NAME] outside the current recommended guidelines for use in the elderly. b) Resident #166 Medical record, on 01/26/10, disclosed this [AGE] year old male resident had been receiving the antidepressant drugs [MEDICATION NAME] 60 mg since January 2009 and [MEDICATION NAME] 15 mg since 11/19/08. Review of current physician orders [REDACTED]. The use of two (2) or more antidepressants (duplicate therapy) elevates the risk of side effects, and the medical record must include physician documentation of the expected benefits that may outweigh the risks. Review of the pharmacist's drug regimen reviews for 2008 and 2009 found no gradual dose reduction of either drug had been attempted. Review of current physician's progress notes for 2009 found no documentation justifying the use of both [MEDICATION NAME] and [MEDICATION NAME] for depression. In an interview on 01/28/10 at 8:45 a.m., the director of nursing (Employee #142) was informed of the use of duplicate antidepressant therapy and documentation by the physician justifying the duplicate therapy was requested. No further information was presented. .",2014-11-01
10897,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,428,D,0,1,BY0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the Lexi-Comp Drug Information Handbook, and staff interview, the consultant pharmacist failed to identify and report to the physician and director of nursing (DON) irregularities in the drug regimens of two (2) of forty-one (41) Stage II sampled residents. Resident #86 had been receiving Flexeril 5 mg three (3) times a day since 11/21/08 with no recommended dose reductions or documentation of the benefits versus risks of continued long term use. According to the Lexi-Comp Drug Information Handbook review, Flexeril is intended for short term use only and should be used with caution in the elderly due to its high anticholinergic effects. The side effects of Flexeril include hallucinations, behavioral changes, constipation, skin changes, dry mouth and lethargy. Medical record review revealed this resident had been experiencing behavioral problems (such as repetitive use of the call light and requests for staff help / attention, continuous yelling, aggression toward staff and other residents, and hallucinations), all of which were potential side effects of Flexeril use. Resident #166 had been receiving Cymbalta 60 mg since January 2009 for depression and Remeron 15 mg since 11/19/08 for depression with no attempts at a drug reduction. The use of two (2) or more antidepressants elevates the risk of side effects, and there was no evidence the physician documented the expected benefits that may outweigh the risks for this duplicate therapy. There was no evidence the consultant pharmacist identified or reported either of these irregularities to the physician or the DON for action. Resident identifiers: #86 and #166. Facility census: 147. Findings include: a) Resident #86 Medical record review, on 01/25/10, disclosed this [AGE] year old female resident had been receiving Flexeril 5 mg TID since 11/21/08 for a [DIAGNOSES REDACTED]. According to the Lexi-Comp Drug Information Handbook, Flexeril is intended for short term use only (not more than two (2) to three (3) weeks) and should be used with caution in the elderly due to its high anticholinergic effects. The side effects of Flexeril include hallucinations, behavioral changes, constipation, skin changes, dry mouth, and lethargy. Medical record review, including a review of nursing notes from 09/08/09 to 01/24/10, found this resident had been experiencing behavioral problems such as repetitive use of the call light, repetitive requests for staff help / attention, continuous yelling, aggression toward staff and other residents, and hallucinations, all of which were potential adverse drug reactions. Review of physician's progress notes found no documentation indicating the long term use of Flexeril had been monitored and the benefits versus risks of the continued use of this drug had been documented. Interview with the director of care delivery (Employee #47), on 01/27/01, at 11:00 a.m., revealed the physician had been using the Flexeril long term for reasons other than relief of muscle spasms. Employee #47 also confirmed the physician had not made any documentation of the benefits versus risks of using the Flexeril outside the current recommended guidelines for use in the elderly. Review of the pharmacist's monthly drug regimen review for 2009 and review of pharmacist's recommendations to the physician disclose no evidence the pharmacist had identified the continued use of Flexeril as an irregularity and notified the physician and DON as required. b) Resident #166 Medical record, on 01/26/10, disclosed this [AGE] year old male resident had been receiving the antidepressant drugs Cymbalta 60 mg since January 2009 and Remeron 15 mg since 11/19/08. Review of current physician orders [REDACTED]. The use of two (2) or more antidepressants (duplicate therapy) elevates the risk of side effects, and the medical record must include physician documentation of the expected benefits that may outweigh the risks. Review of the pharmacist's drug regimen reviews for 2008 and 2009 found no gradual dose reduction of either drug had been attempted. Review of current physician's progress notes for 2009 found no documentation justifying the use of both Cymbalta and Remeron for depression. Review of pharmacist-to-physician communication disclosed no evidence the pharmacist had identified this irregularity and notified the physician and DON as required. Interview with Employee #47, on 01/27/10 at 11:00 a.m., confirmed this irregularity had not been communicated. .",2014-11-01
10898,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,412,D,0,1,BY0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide dental services for one (1) of forty-one (41) Stage II sampled residents due to an information flow problem. The registered dietitian recommended Resident #148 receive a dental consult for loose-fitting dentures; this recommendation was not acted upon before being filed in the medical record. Resident identifier: 148. Facility census: 147. Findings include: a) Resident #147 Medical record review, on 01/27/10, revealed nutrition risk assessment dated [DATE], on which the registered dietitian recorded the need for a dental consult to evaluate loose-fitting dentures. Review of physician orders, physician progress notes [REDACTED]. In an interview on 01/27/10 at 2:30 p.m., the social service worker (Employee #92) reported the social services staff had not been informed of the need or request for a dental consult. In an interview on 01/27/10 at 3:30 p.m., the dietitian (Employee #172) related she was not aware whether the consult had occurred. In a subsequent interview on 01/28/10, Employee #92 confirmed this consult had not been completed, because the recommendation for the consult was not communicated to staff responsible for obtaining orders for and scheduling such consults. .",2014-11-01
10899,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,334,E,0,1,BY0111,". Based on the review of the facility's seasonal influenza immunization tracking log and staff interview, the facility failed to ensure sixteen (16) of twenty-seven (27) Stage II sampled residents, who were currently residing in the facility, received the seasonal influenza vaccine in a timely manner. Record review revealed these sixteen (16) residents either had consents and the vaccine had not been administered, or were alert and oriented and had not been offered the opportunity to receive the vaccine as of 01/28/10. Resident identifiers: #148, #170, #166, #183, #118, #45, #232, #74, #144, #139, #28, #93, #9, #112, #196, and #98. Facility census: 147. Findings include: a) Residents #148, #170, #45, #74, #144, #112, #196, and #98 Review of the facility's seasonal influenza tracking log, on 01/25/10, revealed these residents either already had consents on file or needed telephone follow-up to provide them with the flu vaccine. In an interview on 01/20/10 at 1:30 p.m., the infection control nurse (Employee #164), who was responsible for the coordination of the seasonal flu vaccine administration, revealed consents and information for the vaccine had been mailed out to families of residents who were not able to make their own decisions on 09/24/09. In an follow-up interview at 12:15 p.m. on 01/25/10, Employee #164 confirmed the above residents already had consents and had not yet received the vaccine. b) Residents #166, #183, #118, #232, #139, #28, #93, and #9 Review of the facility's seasonal influenza tracking log, on 01/25/10, revealed these residents had not received the seasonal flu vaccine. In an interview at 12:15 p.m. on 01/25/10, Employee #164 verified the above residents were alert / oriented and capable of making their own health care decisions related to receiving the seasonal flu vaccine, but they had not been offered the vaccine. c) In an interview on 01/27/10 at 3:30 p.m., the director of nursing (Employee #142) agreed the existing process of ensuring residents received the seasonal flu vaccine timely was not adequate. .",2014-11-01
10900,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,520,E,0,1,BY0111,"Based on staff interview, review of employee personnel files, and review of the facility's quality assurance program, the facility failed to ensure employees obtained annual physicals as required by State law (64CSR13-11.6.d.); annual employee physicals had not been completed since April 2009. The facility's quality assurance (QA) process identified this as a problem on 11/19/09, but the facility's QA committee failed to take action in order to ensure the problem was corrected. This occurred for ninety-nine (99) of one hundred and seventy-two (172) employees. Employee identifiers: #1, #2, #4, #5, #8, #9, #10, #11, #12, #13, #14, #17, #18, #19, #22, #25, #27, #29, #30, #32, #33, #35, #36, #37, #40, #42, #43, #44, #45, #48, #49, #50, #53, #55, #57, #58, #59, #62, #63, #64, #65, #66, #67, #70, #73, #74, #75, #76, #79, #82, #83, #85, #87, #88, #90, #91, #92, #94, #95 #99, #100, #102, #105, #111, #112, #114, #117, #118, #119, #120, # 121, #122, #123, #124, #129, #130, #132, #134, #135, #136, #137, #138, #139, #141, #144, #145, #147, #148, #149, #151, #152, #153, #156, #157, #158, #161, #162, #165, #166, and #171. Facility census: 147. Finding include: a) Employees #1, #2, #4, #5, #8, #9, #10, #11, #12, #13, #14, #17, #18, #19, #22, #25, #27, #29, #30, #32, #33, #35, #36, #37, #40, #42, #43, #44, #45, #48, #49, #50, #53, #55, #57, #58, #59, #62, #63, #64, #65, #66, #67, #70, #73, #74, #75, #76, #79, #82, #83, #85, #87, #88, #90, #91, #92, #94, #95 #99, #100, #102, #105, #111, #112, #114, #117, #118, #119, #120, # 121, #122, #123, #124, #129, #130, #132, #134, #135, #136, #137, #138, #139, #141, #144, #145, #147, #148, #149, #151, #152, #153, #156, #157, #158, #161, #162, #165, #166, and #171 Review of sampled personnel files for Employees #5, #48, #105, #112, #135, and #151 failed to find evidence the employees received their annual physicals. The human resources personnel director (Employee #131), when interviewed in the early afternoon on 01/19/10, provided a list of employees who had not received a yearly physical. This list included ninety nine (99) of one hundred and seventy-two (172) employees (see above identifiers). Employee #131 indicated this problem had been identified by the facility's quality assurance process on 11/19/09. Additional information was requested at this time. On 01/21/10 at 1:21 p.m., an interview with the staff development coordinator found the physicals were supposed to be coordinated with the medical director. On 01/21/10 at 4:00 p.m., the administrator agreed the annual physicals were not completed and that this problem had been identified by the facility's quality assurance process identified; however, no plan of action was developed to address and correct the problem. Review of the 10/09/09 ""Facility Quality Assessment and Assurance Committee / Meeting Tools"" for the facility, under Section 1.2. Functions, revealed the following: ""The QAA Committee is responsible for identifying whether potential or actual quality exist issues that require. If there are quality issues, the Committee is responsible for developing plans of action to address them and for monitoring the effect of those actions."" According to State law (64CSR13): ""11.6. Personnel Records. A nursing home shall maintain a confidential personnel record for each employee containing the following information: ... 11.6.d. Results of annual physical; ...""",2014-11-01
10901,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-01-28,309,D,0,1,BY0111,"**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 ensure one (1) of forty-one (41) Stage II sampled residents received appropriate care and services related to [MEDICAL TREATMENT]. Resident identifier: #93. Facility census: 147. Findings include: a) Resident #93 1. An interview with the resident, on 01/25/10 at 3:00 p.m., found the resident went to outpatient [MEDICAL TREATMENT] three (3) days per week, leaving at around 5:30 a.m. and getting back to the facility around 11:30 a.m. on these treatment days. According to the resident, she ate breakfast before leaving, took a snack with her, and then returned to the facility for lunch. The resident also related her blood pressure was checked by facility staff when she returned from [MEDICAL TREATMENT] and the nurse checked her shunt each shift. The resident reported she was on a regular diet with double entrees at breakfast. The resident was also wearing a splint to the left lower arm. 2. Review of the weight records for this resident found she was only weighed monthly by the facility. 3. Review of the communication forms the facility sent to [MEDICAL TREATMENT] for the previous three (3) months found the bottom of the form was blank. Interview with a licensed practical nurse (LPN - Employee #141), on 01/27/10 at 1:30 p.m., found this was all that was received from the [MEDICAL TREATMENT] center. She reported that, after returning from [MEDICAL TREATMENT], the resident's blood pressure was taken. She also reported the resident's graft was assessed during each shift for thrills and bruits. Review of the [MEDICAL TREATMENT] communication book and the medical record for the resident did not find any evidence the facility received information for the resident or requested any information from the [MEDICAL TREATMENT] center since 12/15/09. A review of the [MEDICAL TREATMENT] communication book found the facility sent a communication form to the [MEDICAL TREATMENT] center each time the resident went to [MEDICAL TREATMENT], and the top part was filled out by the facility, but the bottom was left blank and not filled out by the [MEDICAL TREATMENT] center. During an interview with the registered nurse (RN) supervisor for the second floor (Employee #47), on 01/26/10 at 12:45 p.m., she said someone called the [MEDICAL TREATMENT] center on 09/18/09, and spoke with the nurse manager at the [MEDICAL TREATMENT] center, who agreed they would fax notes to the facility the following day and would speak with the nurses regarding completion of the note in the binder. Notes from the last thirty (30) days were requested. Employee #47 presented a nursing note that reflected the same information. Further review of the medical record did not find evidence the notes were obtained from the [MEDICAL TREATMENT] center or that any subsequent attempts had been made by the facility to address the communication difficult with the [MEDICAL TREATMENT] center. The nursing notes indicated, on 09/19/09, the resident was sent to the emergency room from [MEDICAL TREATMENT] due to ""non-responsiveness and being very confused before that."" 4. On 01/27/10 at 2:30 p.m., interview with a registered nurse at the [MEDICAL TREATMENT] center ([MEDICAL TREATMENT] Employee #1) found the center did take the resident's weight before and after [MEDICAL TREATMENT] and completed blood pressure, fluid, and graft assessments. She reported there was a treatment sheet that was supposed to accompany the resident back to the facility, which recorded what was done during [MEDICAL TREATMENT], including any treatments, assessments, labs, or physician's orders [REDACTED]. The information was faxed to the surveyor at 3:22 p.m. on 01/27/10 at 3:22. 5. An interview with the director of nursing (DON), on 01/26/10 at 1:00 p.m., found the [MEDICAL TREATMENT] center did not choose to communicate with the facility via the communication form sent with the resident to [MEDICAL TREATMENT]. Information from the [MEDICAL TREATMENT] center, faxed to the facility on [DATE], indicated labs were drawn between 06/11/09 and 11/18/09 and contained one (1) progress note from the [MEDICAL TREATMENT] center (dated 12/16/09) and physician's orders [REDACTED]. 6. Review of the agreement with the administrator, on the late afternoon of 01/26/10, found no requirement that the [MEDICAL TREATMENT] center communicate with the facility. The agreement (dated 11/14/07) also indicated the facility was responsible for ""preparing and maintaining care plans with measurable objectives and timetables to meet patient's medical, nursing, and psychological needs, including the following: Alteration in fluid volume; Potential for bleeding; Care of access site; Alteration of nutrition; alteration in skin integrity; medications to be held prior to [MEDICAL TREATMENT]; and provisions of medications and meals which will be missed during [MEDICAL TREATMENT] treatment."" Review of the resident's current care plan (with a revision date of 12/17/09) found a plan addressing bilateral [MEDICAL CONDITION] of the lower legs related end-stage [MEDICAL CONDITION], but it did not address fluctuations of weight or how the facility would monitor the resident's fluid volume status, except for monitoring skin integrity and [MEDICAL CONDITION]. The care plan did not include how the facility would communicate with the [MEDICAL TREATMENT] center regarding the resident's status; care of the resident's [MEDICAL TREATMENT]; which medications were be held prior to [MEDICAL TREATMENT]; and/or how the resident's meals were to be provided around the [MEDICAL TREATMENT] treatment schedule. 7. A request was made for the facility's policies and procedures on 01/26/10 in the late afternoon. On 01/27/10 at mid-morning, staff provided the facility's policy titled ""[MEDICAL TREATMENT] Hemo: AV Fistula or Graft Care"" (with a revision date of 03/16/01). The policy stated that, upon returning from [MEDICAL TREATMENT] treatment, the resident was to be observed for ""1. Active bleeding, and if noted, apply pressure with gloved hand and gauze dressing until bleeding stops - usually 5-10 minutes. If the bleeding is copious, old direct pressure and summon assistance and arrange for transport to the emergency room for further intervention; 2. The fistula / graft was to be auscultated for swinging bruit indicating active circulation to area; 3. Palpating the fistula / graft for buzzing pulse sensation thrill indicting patency to the area. The [MEDICAL TREATMENT] or physician was to be contacted if the thrill and or bruit could not be located. In addition, blood pressure or blood draws were not be taken from the extremity with the fistula / graft. Also tight clothing, jewelry or watch were not be worn on the extremity with the fistula / graft."" 8. Review of the bottom of the communication form sent to [MEDICAL TREATMENT] by the facility found it should be completed by the [MEDICAL TREATMENT] center to include pre/post-[MEDICAL TREATMENT] vital signs and weights, any medication given, complications, nutritional concerns, lab values, post-[MEDICAL TREATMENT] instructions, any new physician's orders [REDACTED]. 9. Review of the resident's weights, on 01/21/10, found the resident's weights were: 172.7 pounds on 05/01/09; 162.1 pounds on 06/03/09; 161.6 pounds on 07/10/09; 156.3 pounds on 08/10/09; 156 pounds on 09/10/09; 154.4 pounds on 10/14/09; 154.9 pounds on 11/18/09; 146.8 pounds on 12/14/09; 142.9 pounds on 12/15/09; 143.6 pounds on 12/21/09; 144.2 pounds on 12/24/09; and 142.4 pounds on 01/12/09. Review of the care plan (with a revision date of 12/17/09) found a problem identified for this resident was [MEDICAL CONDITION] to the lower legs related to [MEDICAL CONDITION] and the resident's ""weight might fluctuate due to [MEDICAL TREATMENT]"". One (1) of the interventions was to ""weigh per order"" and monitor the results. Review of the January 2010 monthly physician's recap orders failed to find any orders regarding the frequency at which staff was to weigh the resident. 10. Review of the January 2010 monthly physician's orders [REDACTED]. One (1) stated, ""Regular diet with double entree at breakfast."" Another stated, ""Low Potassium diet, no fruit."" The resident indicated, during the interview noted above on 01/25/10, she received a regular diet. 11. On 12/08/09, the resident fell and fractured the left wrist. During the 01/25/10 interview, the resident indicated she was wearing a splint due to the fall. A review of the care plan (with a revision date of 12/17/09) found the resident's fingers of her left arm were to be checked for circulation, warmth, and [MEDICAL CONDITION] each shift. However, the care plan did not address assessments of the resident's graft (which was in the left arm) and/or care instructions for this extremity. .",2014-11-01
10902,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-07-22,309,D,1,0,SC5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility provide necessary care and services to assist two (2) of eleven (11) sampled residents in attaining or maintaining their highest practicable physical well-being. Staff did not conduct a thorough physical assessment or notify the physician when Resident #60 had difficulty swallowing her medications and began to vomit. Staff did not initial the facility's bowel protocol timely when Resident #59 did not have a bowel movement on the third consecutive day. Resident identifiers: #60 and #59. Facility census: 58. Findings include: a) Resident #60 On [DATE] at approximately 3:00 p.m., review of Resident #60's medical record revealed she was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. An interview with a family member revealed the resident came to the facility for rehabilitation after sustaining a left [MEDICAL CONDITION] at home. The family member said the resident expired at a local hospital, and the hospital indicated she died from septic shock. The family member said the resident had a history of [REDACTED]. On [DATE], the resident had a basic metabolic panel (BMP) with the following abnormal values: - Glucose - 157 - High (normal range 65 - 99) - BUN - 46 - High (normal range 5 - 18) - Serum Creatinine - 2.15 - High (normal range 0.57 - 1.00) Employee #37 (a registered nurse) provided a copy of the resident's weights and vitals summary. The summary gave the following information: - [DATE]: 136.2 pounds. - [DATE]: Blood pressure - ,[DATE] , temperature - 96.8 , pulse - 60, respirations - 30 Nursing notes, dated [DATE] at 23:30 (11:30 p.m.) and [DATE] at 23:30 (11:30 p.m.), stated respectively that the resident had ""decreased movement"" and ""difficulty"" when swallowing her medications. A nursing note, on [DATE] at 22:25 (10:25 p.m.), stated, ""... Observations: alert, even resp. skin w/d (warm / dry), took pm (evening) medications crushed in applesauce resident spit/vomited all 9 pm medications out, resident able to eat ok per day shift worker, but medications resident spit/vomits out, will report to oncoming nurse, has happened several times before resting in bed with call bell in reach."" A late entry nursing note, dated [DATE] at 23:20 (11:20 p.m.), stated, ""... Took pm meds with difficulty, started to gag but was able to keep down. ... Action/nursing interventions: will monitor Resident's response."" There was no evidence in the medical record of staff having completed a thorough nursing assessment of the resident related to the vomiting, nor was there evidence to reflect staff notified the physician of the resident's vomiting or difficulty taking her medications. On [DATE] at approximately 12:00 p.m., the director of nursing (DON - Employee #37) was interviewed regarding Resident #60. The DON reviewed the medical record as well as other reports related to Resident #60 and could not locate any documentation showing where staff had assessed the resident after she had difficulty swallowing and/or keeping her medications down. Employee #77 (a corporate registered nurse) also reviewed the medical record and verified the facility had not checked the resident's vital signs or called her physician when she experienced difficulty taking her medications and vomited the night time medications. -- b) Resident #59 Review of the medical record found Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the standing orders, signed by the treating physician on [DATE], found a protocol which was to be instituted for constipation. The standing orders specified if no bowel movement on Day 3, give MOM (milk of magnesia) 30 ml in the morning. Review of the activities of daily living (ADL) record found staff documented that the resident had no bowel movements on [DATE], [DATE], or [DATE]. The medical record contained no evidence to reflect that staff instituted the bowel protocol as ordered for this resident. An interview with Employee #77, on [DATE] at 12:30 p.m., confirmed the resident should have received or been offered MOM on [DATE].",2014-11-01
10903,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,201,B,0,1,OF0Z11,"Based on staff interview and review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with four (4) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This had the potential to affect all residents in the facility who are transferred or discharged . Facility census: 92. Findings include: a) Review of the uniform discharge notice of transfer / discharge form provided by the facility revealed the following: ""If you disagree with this transfer/discharge or wish to appeal this transfer/discharge...:"" This was followed by the names and contact information of the State Long-Term Care Ombudsman, Medicaid Fraud, and the WV Advocates. Below the above list of names and addresses was ""For Medicaid Residents: Please include the provided self addressed stamped envelope which includes the address of the.... Inspector General"". This uniform notification form contained the following error: The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the three (3) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Interview with the director of nursing, on 09/10/09, revealed the facility changed this form a year or more ago and they were under the impression this form in its current format was appropriate. .",2014-11-01
10904,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,281,E,0,1,OF0Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow its policies regarding correct administration of inhalers and for daily quality control checks for glucometers. The latter had the potential to affect diabetic residents on the West wing. Resident identifier: #7. Facility census: 92. Findings include: a) Resident #7 During medication pass observation 09/09/09 at 9:00 a.m., the nurse (Employee #69) handed Resident #7 a [MEDICATION NAME] inhaler with no verbal instructions regarding how to use it. He inhaled two (2) inhalations of [MEDICATION NAME] in rapid succession. On 09/10/09 at approximately 4:00 p.m., the director of nursing (DON) produced a Medication Administration Competency Checklist. Item #14 on the checklist specified that, when metered dose inhalers are used, the resident is to hold his breath for five (5) to ten (10) seconds after the first inhalation, then pause for one (1) to two (2) minutes between inhalations of the same medication. This policy was not followed with Resident #7. b) West wing On 09/10/09 at approximately 3:00 p.m., review of the Assure Blood Glucose Meter Daily Quality Control Record for the West front hall revealed blank spaces from 09/01/09 through 09/08/0908 and 09/10/09, for which staff was to record cleaning the meter and testing the strips each day. The only recorded strip testing for the month occurred on the 7:00 p.m. to 7:00 a.m. shift of 09/09/09. Notations were entered on 09/01/09 and 09/09/09 documenting the Assure Test Strip Lot # was and the meter was cleaned. Interview with Employee #83 at this time revealed that night shift staff was responsible for testing the strips daily and for cleaning the glucometer. On 09/10/09 at approximately 4:00 p.m., the DON produced a policy which stated the 11-7 charge nurse will do the quality control checks on a nightly basis of any glucometers in use and will take proper steps if the control results are outside the acceptable limits to ensure that the blood glucose system daily quality control system maintains quality assurance. On 09/10/09 at approximately 4:30 p.m., the administrator was informed of the above findings. During the exit conference on 09/11/09, the DON stated she was unable to find the August daily quality control record to see if, perhaps, the information had inadvertently been recorded on the August daily quality control record. .",2014-11-01
10905,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,371,F,0,1,OF0Z11,"Based on observation and staff interview, the facility failed to ensure food was prepared in a manner that maintains proper sanitation conditions by allowing an individual to prepare food items without a facial hair restraint. This practice had the potential to affect all residents in the facility who consume foods prepared and served from this central location. Employee identifier: #13. Facility census: 92. Findings include: a) Employee #13 During the initial tour of the facility at 2:30 p.m. on 09/08/09, observation found Employee #13 had facial chin hair that was not covered by any type of hair restraint. According to the 2005 Food Code section 2-402.11, ""FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; ..."" This was discussed with the consultant dietitian on the morning of 9/10/09. .",2014-11-01
10906,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,279,E,0,1,OF0Z11,"Based on observation and staff interview, the facility failed to ensure care plans for residents on the facility's Alzheimer's / dementia unit were accessible to staff who cared for the twenty two (22) residents on the unit. Facility census: 92. Findings include: a) During the annual resurvey from 09/08/09 through 09/11/09, the care plans for the twenty-two (22) residents residing on the facility's Alzheimer's / dementia unit were not readily available for review. On 09/08/09, random interviews with staff found the care plans were not readily accessible for staff who provided care for the residents. They indicated the care plans were usually in the office of the minimum data set (MDS) assessment nurse. On 09/10/09 at 4:00 p.m., the MDS nurse, when interviewed, indicated her office door was left open and anyone could come into her office to look at the care plans. She also said she worked on the care plans during the day and put them back at the nurse's station in the evening. .",2014-11-01
10907,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,225,D,0,1,OF0Z11,"Based on personnel record review and staff interview, the facility failed to ensure a nursing assistant abuse registry search was completed, to assure the current status of a registered long-term nursing assistant and to check for findings of abuse, neglect or misappropriation of resident property, for one (1) of five (5) employees recently hired at the facility. Employee #3 was hired by the facility as a nursing assistant, and the registry check was not done prior to hiring as required. Employee identifier: #3. Facility census: 92. Findings include: a) Employee #3 Personnel record review, on 09/09/09, found Employee #3 had been hired as a nursing assistant on 07/02/09. There was no evidence in this employee's personnel file to reflect the facility had verified the registration status with the West Virginia Long-Term Care Nursing Assistant Program and checked for findings of abuse, neglect or misappropriation of resident property. During an interview on 09/09/09 at 10:30 a.m., the personnel director confirmed the nursing assistant abuse registry had not been check prior to hiring Employee #3. .",2014-11-01
10908,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2011-07-13,250,D,1,0,M5W211,". Based on family interview, a review of the notice of decision letter from the West Virginia Department of Health and Human Resources, and staff interview, the facility failed to respond in a timely manner to requests for information needed to continue Medicaid eligibility. A request was made for information that was not provided the Medicaid office, and this resulted in the benefits for medical assistance being stopped for one (1) of six (6) sampled residents, who was no longer eligible for benefits (which included room and board at this nursing home). Resident identifier: #78. Facility census: 91. Findings include: a) Resident #78 During an interview on 07/12/11 at 8:00 a.m., a family member of Resident #78 reported this resident was ""no longer eligible for her Medicaid services for payment, because the facility did not do what they needed to do and she lost her Medicaid."" During an interview with business office staff (Employee #43) on 07/12/11 at 1:15 p.m., Employee #43 reported the former business office manager did not send in the requested information to Medicaid, and the facility received a letter saying this resident's benefits were going to stop. According to Employee #43, they were working on getting the Medicaid benefits restarted for Resident #78, but they had to collect the data as if the resident were newly applying for Medicaid instead of just continuing the benefit. She stated that, if the requested information had been turned in timely, they could have just continued her services without having to obtain all of the information needed for an initial application. A letter from the WV Department of Health and Human Resources, dated 04/06/11, to the resident at the facility stated: ""Your benefits will stop and you will not receive this benefit after April 2011."" The reason stated for discontinuing the resident's beneits was: ""You did not turn in all requested information."" As of 07/11/11, this issue was still not resolved, and the facility was assisting with re-applying for Medicaid benefits. The only information that would have been required to continue her Medicaid benefits was ""proof of the value of her checking account"". .",2014-11-01
10909,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2011-07-13,278,D,1,0,M5W211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to complete an accurate assessment for one (1) of six (6) 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: #18. Facility census: 91. Findings include: a) Resident #18 Record review revealed this resident was admitted on [DATE], to the facility's Alzheimer's Unit. He had been a patient in the hospital's behavior unit. According to his physician's orders [REDACTED]. According to his medication administration records (MARs), he had received this [MEDICAL CONDITION] drug each night at bedtime. Review of the resident's MDS, with an assessment reference date of 04/04/11 found the assessor indicated, in Section N0400, that this resident had not received a hypnotic medication in the previous seven (7) days. During an interview with the MDS coordinator (Employee #7) on 07/13/11 at 11:00 a.m., she confirmed this assessment had been coded incorrectly. She stated she was doing a correction on this assessment. She also verified that no care area assessment had been completed for use of this medication due to the incorrect coding. .",2014-11-01
10910,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2011-07-13,323,D,1,0,M5W211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide an environment as free of accident hazards as possible for one (1) of six (6) sampled residents who sustained two (2) falls. The resident's drug regimen, which included the administration of an hypnotic medication every night for insomnia, was not reviewed to determine whether this medication was a possible causal or contributing factor to the falls. Resident identifier: #18. Facility census: 91. Findings include: a) Resident #18 Record review revealed Resident #18 was admitted to the facility's Alzheimer's Unit on 03/28/11, after an inpatient stay on a psychiatric unit. According to the medical record, this [AGE] year old male was receiving the hypnotic medication ""Restoril 22.5 mg by mouth at bedtime everyday for insomnia."" This medication was ordered while he was a patient on the psychiatric unit prior to his admission to this facility and was continued after his admission to the nursing facility. Record review revealed this resident had sustained two (2) falls during his stay at this facility. On 06/06/11 at 5:20 p.m., when he attempted to get up out of his bed, he slid to the floor. On 06/10/11 at 5:00 a.m., he was found on the floor; nursing documentation noted his gait was unsteady at that time and he was confused. The post-fall evaluation assessments and the care plan did not identify that this resident was receiving a large dose of Restoril, even after he experienced two (2) falls. There was no evidence that the facility considered the resident's falls risk was increased with this medication's use. A care plan (dated 06/06/11) was written after the resident was found on the floor following his first fall. There was no evidence his medications were reviewed or that the risks and benefits for the continued use of Restoril were discussed. The intervention in the care plan related to medication use simply stated: ""Meds as ordered."" The resident fell again on 06/10/11 at 5:00 a.m. The care plan had interventions listed on the acute plan, and the appropriate interventions were checked if they were to be applied. One (1) intervention stated: ""13. Evaluate with the physician the potential impact of medications..."" This was not checked. There was no evidence in the care plan of that medication use had been considered as a possible contributing factor to the resident's falls. During an interview with the minimum data set assessment (MDS) nurse (Employee #7) on 07/13/11 at 11:00 a.m., she confirmed the resident's care plan did not identify the need to evaluate the use of this medication as a possible causal or contributing factor with respect to his falls. According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), on Page 1177, Restoril is a benzodiazepine, and ""... Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly). ..."" On Page 1178, the drug handbook noted that, for the elderly or debilitated patients, dosing is 15 mg daily. Resident #18 was receiving 22.5 mg daily. .",2014-11-01
10911,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2011-07-13,329,D,1,0,M5W211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure, for one (1) of six (6) sampled residents, that each resident's medication regimen was free from unnecessary drugs in excessive doses, for an extended period of time in the absence of a trial gradual dose reduction, and in the absence of an evaluation of risks versus benefits for its continued use. Resident #18 was receiving an hypnotic medication ([MEDICATION NAME]) since his date of admission in March 2011. The medication was ordered in a daily dose that exceeded the recommended daily dose for use in the elderly population. The medication was also continued for more than three (3) months without an attempt at gradual dose reduction and in the absence of an assessment of the risks versus benefits for its continued use. Resident identifier: #18. Facility census: 91. Findings include: a) Resident #18 Record review revealed Resident #18 was admitted to the facility's Alzheimer's Unit on 03/28/11, after an inpatient stay on a psychiatric unit. According to the medical record, this [AGE] year old male was receiving the hypnotic medication ""[MEDICATION NAME] 22.5 mg by mouth at bedtime everyday for [MEDICAL CONDITION]."" This medication was ordered while he was a patient on the psychiatric unit prior to his admission to this facility and was continued after his admission to the nursing facility. The consultant pharmacist reviewed this resident's medication regimen on 04/28/11. She recommended this medication ([MEDICATION NAME] 22.5 mg) be slowly tapered and discontinued, because ""it is recommended to limit the use of sedative-hypnotics to short term use (10-14 days) as long term use increases the risk for adverse events and dependence which often outweighs the benefit of continued therapy."" She further noted that [MEDICAL CONDITION] may occur upon admission to a facility, but as individuals become accustomed to new surroundings, the [MEDICAL CONDITION] often subsides. The pharmacist further stated that, if this therapy were continued, it was recommended that the prescriber document an assessment of risks verses benefit, indicating that the medication continues to be a valid therapeutic intervention for this individual, and that the facility's interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. There was no evidence to reflect the physician acted upon this recommendation by providing this documentation. Record review revealed this resident had sustained two (2) falls during his stay at this facility. On 06/06/11 at 5:20 p.m., when he attempted to get up out of his bed, he slid to the floor. On 06/10/11 at 5:00 a.m., he was found on the floor; nursing documentation noted his gait was unsteady at that time and he was confused. According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), on Page 1177, [MEDICATION NAME] is a benzodiazepine, and ""... Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly). ..."" On Page 1178, the drug handbook noted that, for the elderly or debilitated patients, dosing is 15 mg daily. Resident #18 was receiving 22.5 mg daily. Also on Page 1178, the following was noted under the subheading ""Geriatric Considerations"": ""... Hypnotic use should be limited to 10-14 days. If [MEDICAL CONDITION] persists, the patient should be evaluated for etiology."" The director of nursing (DON - Employee #44), when interviewed on 07/13/11 at 1:00 p.m., was made aware that there was no supporting documentation for this medication use. She was not able to find further evidence to support the use of this medication.",2014-11-01
10912,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2011-07-28,514,D,1,0,TF5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted standards of practice that were complete and accurately documented. The medical record of one (1) resident lacked sufficient documentation to chronicle an acute episode. In another resident's discharge summary, the physician's signature was not dated to identify when the summary was completed. A third resident's physician's orders [REDACTED]. Resident identifiers: #34, #51, and #37. Facility census: 57. Findings include: a) Resident #34 Review of Resident #34's medical record found she had developed a nose bleed the afternoon of 06/30/11. An INR (a test to assess the anticoagulation effect of [MEDICATION NAME]) was found to be high. She was sent to the hospital later that evening after injections of Vitamin K failed to stop the bleeding. - The nursing entries (typed as written) for this acute episode on 06/30/11 were: - 12:23 p.m. - ""Resident refused to eat her lunch ,then wanted ice for Pepsi."" - 3:30 p.m. - ""Lab calls this nurse with critical PT/INR of 42.3/8.7"" - 3:45 p.m. - ""Doctor on call notified of PT/INR Receive new order Vitamin K PO (by mouth) 2.5 mg times one dose now."" - 3:50 p.m. - ""Dr. (Name) notified of by mouth Vitamin K availability. Receive order to discontinue [MEDICATION NAME] 5.5 mg. Dr. (Name) states 'Will call back.'"" - 5:03 p.m. - ""Dr. (Name) call this facility. Receives order Vitamin K 5 mg Intramuscular times one dose now. Re-check PT/INR in morning."" - 5:10 p.m. - ""Vitamin K 5 mg per doctor order administered at this time to resident's left ventro-gluteal area. Resident tloerated well."" - 8:30 p.m. - ""Dr. (Name) notified of slow results of earlier Vitamin K order. Receive new order Vitamin K 5 mg Intramuscular times one dose now and CBC in morning."" - 8:35 p.m. - ""Vitamin K 5 mg Intramuscular administered at this time per doctor's order to right ventro-gluteal area. Resident tolerated well."" - 10:09 p.m. - ""Resident's vital signs B/P 94/52 Temperature 95.7 Pulse 94 Respirations 28 Pulse oximeter 86% DR notified at this time. Receive order Transport resident to (Name) Emergency Department."" - 9:30 p.m. - ""Medical Power of Attorney notified of Resident's status."" - 10:21 p.m. - ""Medical Power of attorney notified of doctor order to transport."" - 10:22 p.m. - ""MPOA request's (Name) Hospital."" The resident was then sent to the hospital. She returned to the facility at 4:36 a.m. on 07/01/11. - In an interview at 3:47 p.m. on 07/26/11, the director of nursing (DON) said she and Employee #63 (a registered nurse - RN) had checked the resident that afternoon. At that time, the resident had some blood on her finger tips and around her nose. - On 07/26/11 at approximately 4:00 p.m., Employee #63 was interviewed. She said the resident had some blood on her fingertips and dried blood on her face / nose. The nurse said the resident would pick her nose and that a care plan had been developed regarding this. She said she had probably left around 5:30 p.m. or 6:00 p.m. that evening. She had not heard of the resident bleeding any more. In a subsequent interview on 07/27/11 at 9:00 a.m., this nurse said she had left at 4:36 p.m. that day - she had the business office look it up. - On 07/26/11 at approximately 4:15 p.m., Employee #54 (a licensed practical nurse - LPN) was asked if she remembered this occurrence. She said she had only heard about the resident's nose bleed from the night shift nurse. She had been told the resident had to be sent out to the hospital. Nothing had been said about a lot of bleeding or anything. - On 07/27/11 at 2:42 p.m., the nurse who wrote most of the notations that day (Employee #22) was interviewed. She stated her main concern about the resident that evening had been her vital signs. When asked about how much the resident had bled, she said she really did not know. According to this nurse, they had changed the linens frequently, so they could tell whether the nose bleed had slowed or not. When asked to estimate how much she thought the resident had bled on her shift, she guessed a quarter of a cup. She said she had not heard anyone say anything about bleeding before she had marked on the Medication Administration Record [REDACTED]. (The MAR for that date was reviewed, and there was no indication the resident had exhibited any bleeding. The MAR indicated [REDACTED].) The nurse said the doctor had said the Vitamin K injection would take a couple of hours to work. After a couple of hours, the bleeding had slowed, but she was still bleeding. The nurse said the resident's vital signs had been checked - she thought she had recorded them - hoped she had. (No vital signs for this period could be found in the nurses' notes, the vital signs report, Medication Administration Record, [REDACTED]. The nurse continued, saying that after about an hour (after the second Vitamin K injection) it was felt the Vitamin K was not helping much. The resident's vital signs had been checked, and the physician had been notified. When asked about the resident's mental status, especially at the time the decision was made to transfer the resident to the hospital, the nurse said, ""I think she was pretty low on her LOC (level of consciousness)."" - There was a lack of documentation to chronicle this resident's acute episode. The resident, who was on the anticoagulant ([MEDICATION NAME]) with a significantly elevated INR, had a nose bleed that persisted for hours. There was no evidence of on-going assessment of the resident's vital signs, mental status, or overall condition. There was no indication of the continued bleeding, no clear indication why it was necessary to contact the physician for the second dose of Vitamin K, and no clear indication why it was necessary to transfer the resident to the hospital. -- b) Resident #51 Review of the medical record for Resident #51 revealed a discharge summary form that contained no date by the physician's signature. Due to this lack of a dated signature, it could not be ascertained whether the physician completed the discharge summary in a timely manner. -- c) Resident #37 Review of physician orders [REDACTED]. An interview with the dietary manager (Employee #34), on 07/27/11 at 12:45 p.m., revealed the resident no longer received the Mighty Shakes with meals, that it had been discontinued. The dietary manager stated the resident did not like the Mighty Shakes and preferred yogurt and a piece of fruit. The dietary manager provided a communication form showing the Mighty Shakes had been discontinued and put in the dietary system on 08/27/10. The order for Mighty Shakes was carried forward on the monthly physician orders [REDACTED].",2014-11-01
10913,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2011-07-28,502,D,1,0,TF5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records and interviews with staff, the facility had failed to provide laboratory services to meet the needs of one (1) of thirty-seven (37) residents on the Stage II sample. The resident was receiving an anticoagulant ([MEDICATION NAME]). The physician had been ordering tests to determine the dosage of the anticoagulant and adjusting the dosage according to the results of the tests. Two (2) tests were found to have been omitted. This resulted in no test being done for almost thirty (30) days. When the test was done, the result was abnormally high at 8.7 (with a desired range of 2.0 to 3.0). Resident identifier: #34. Facility census: 57. Findings include: a) Resident #34 Review of the resident's medical record found she had required an emergency room visit on 06/30/11. She had developed a nose bleed that persisted for hours and persisted despite injections of Vitamin K. On this same date, it was found her INR was 8.7 - a high value (the laboratory's range for this test was 2.0 - 3.0). (INR: International normalized ratio, a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Homeostasis for reporting the results of blood coagulation (clotting) tests. All results are standardized using the international sensitivity index for the particular [MEDICAL CONDITION] reagent and instrument combination utilized to perform the test. (http://www.medterms.com/script/main/art.asp?articlekey=9185)) There was no order for routine INRs. A nurse would contact the physician with the results of the test, and the physician would order a dosage change for the [MEDICATION NAME], if indicated. If the dosage changed or the physician wanted to recheck the INR, he or she would order another INR to be completed. -- Review of the resident's lab work results found there were INRs that had been ordered, for which no results were not found. The lab section of the resident's record was reviewed. The most recent PT/INR studies were as follows ((L) = low; (H) = high): (Date of lab - PT - INR - any notations made on the lab results) 04/05/11 - 15.3 - 1.4 (L) 04/13/11 - 13.8 - 1.2 (L) 04/18/11 - 16.2 - 1.6 (L) 05/03/11 - 16.5 - 1.6 (L) - ""On 4/18 INR 1.6 on 5.5 [MEDICATION NAME] 6 mg [MEDICATION NAME] Repeat PT/INR on 5/11/11"" (On 05/04/11, the physician order [REDACTED]. The results of the 05/11/11 labs were not found.) 05/23/11 - 30.6 - 4.7 (H) - ""6 mg now hold [MEDICATION NAME] to recheck tomorrow 05/24/11"" 05/24/11 - 27.0 - 3.7 (H) - ""Hold [MEDICATION NAME] tonight PT INR 05/25/11"" 05/25/11 - 23.2 - 2.8 - ""Start 5 mg repeat INR Tuesday"" 05/31/11 - 14.6 - 1.4 (L) (On 06/01/11, the physician ordered a PT/INR to be done in three (3) days (on 06/04/11). The results of the 06/04/11 labs were not found.) 06/30/11 - 42.3 - 8.7 (H) (This elevated INR was well above previous results for which the physician had ordered the [MEDICATION NAME] held.) -- The afternoon of 07/27/11, Employee #63 (a registered nurse - RN) was asked where additional reports might be found. She said she would check the resident's thinned records. Some of the missing reports were found and copies provided. The morning of 07/28/11, the director of nursing (DON) was asked to try to locate the reports for INRs that were to have been done on 05/11/11 and 06/04/11. She later reported the studies had not been done. -- The PT/INR ordered on [DATE] to be done on 05/11/11 could not be located. When a test was done on 05/23/11, it was high and the [MEDICATION NAME] had to be held. No PT/INR could be found for 06/04/11. No PTs/INRs were found for the period between 05/31/11 and 06/30/11. The 06/30/11 INR of 8.7 was a high value. On 06/30/11, the resident developed a nose bleed. Based on what was learned through interviews with staff, the bleeding persisted for more than eight (8) hours. During this time, the physician was notified and ordered an injection of Vitamin K (used to reverse the effects of [MEDICATION NAME] ([MEDICATION NAME])). The resident continued to have a nose bleed. A second injection of Vitamin K was ordered and administered. The nose bleed continued and there was a concern about the resident's vital signs. She was transferred to the emergency room for further evaluation and treatment. In the emergency room , her nose was packed and she was given two (2) units of fresh frozen plasma (FFP). An INR done in the emergency room was 9.3. (Note: This resident was known to pick at her nose, and this may have caused the bleeding to occur initially, but it would not have been the cause of the bleeding to persist for hours.) (See also citation at F309.) .",2014-11-01
10914,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2011-07-28,309,G,1,0,TF5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and resident interview, the facility failed to ensure a resident received care and services to assist the resident in maintaining her highest practicable level of well-being. Tests to determine the anticoagulant effect of [MEDICATION NAME] were not done in a timely manner. Nearly a month after lab tests had been ordered, a test was done - the results of which were found to be significantly elevated. The resident developed a nose bleed which did not respond to Vitamin K injections. She was subsequently sent to the hospital for treatment, which included insertion of nasal tampons and administration of fresh frozen plasma (FFP). Resident identifier: #34. Facility census: 57. Findings include: a) Resident #34 Review of Resident #34's medical record found she had been on [MEDICATION NAME] (a blood thinner). On 06/30/11, it was noted her PT/INR (laboratory tests to determine how much the [MEDICATION NAME] had affected her bleeding times) were elevated. Her PT ([MEDICATION NAME]) was 42.3 (the mean normal is 12.6), and her INR was 8.7 (reference range is 2.0 - 3.0). (INR: International normalized ratio, a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Homeostasis for reporting the results of blood coagulation (clotting) tests. All results are standardized using the international sensitivity index for the particular [MEDICAL CONDITION] reagent and instrument combination utilized to perform the test. (http://www.medterms.com/script/main/art.asp?articlekey=9185)) She had developed a nose bleed at this time. She was noted to have received two (2) injections of Vitamin K in an attempt to reverse the blood thinning effects of the [MEDICATION NAME]. After the second injection did not cause the bleeding to stop, the resident was sent to the hospital for evaluation and further treatment. The nursing entries (typed as written) for this acute episode on 06/30/11 were: - 12:23 p.m. - ""Resident refused to eat her lunch ,then wanted ice for Pepsi."" - 3:30 p.m. - ""Lab calls this nurse with critical PT/INR of 42.3/8.7"" - 3:45 p.m. - ""Doctor on call notified of PT/INR Receive new order Vitamin K PO (by mouth) 2.5 mg times one dose now."" - 3:50 p.m. - ""Dr. (Name) notified of by mouth Vitamin K availability. Receive order to discontinue [MEDICATION NAME] 5.5 mg. Dr. (Name) states 'Will call back.'"" - 5:03 p.m. - ""Dr. (Name) call this facility. Receives order Vitamin K 5 mg Intramuscular times one dose now. Re-check PT/INR in morning."" - 5:10 p.m. - ""Vitamin K 5 mg per doctor order administered at this time to resident's left ventro-gluteal area. Resident tloerated well."" - 8:30 p.m. - ""Dr. (Name) notified of slow results of earlier Vitamin K order. Receive new order Vitamin K 5 mg Intramuscular times one dose now and CBC in morning."" - 8:35 p.m. - ""Vitamin K 5 mg Intramuscular administered at this time per doctor's order to right ventro-gluteal area. Resident tolerated well."" - 10:09 p.m. - ""Resident's vital signs B/P 94/52 Temperature 95.7 Pulse 94 Respirations 28 Pulse oximeter 86% DR notified at this time. Receive order Transport resident to (Name) Emergency Department."" - 9:30 p.m. - ""Medical Power of Attorney notified of Resident's status."" - 10:21 p.m. - ""Medical Power of attorney notified of doctor order to transport."" - 10:22 p.m. - ""MPOA request's (Name) Hospital."" The resident left the facility at 11:00 p.m. She returned at 4:36 a.m. on 07/01/11 with packings in nose. It was noted there was a moderate amount of bleeding. The packings were to be removed the next shift. -- In an interview on 07/27/11 at 2:42 p.m., Employee #22 (the nurse who had cared for the resident on 06/30/11) said she had been mainly concerned about the resident's vital signs. She had called the doctor, and received an order for [REDACTED]. A second order for Vitamin K had been received. After about an hour, it did not seem like the Vitamin K was working, so she had them check the vital signs again and called the doctor. That time, the doctor said to send her out to the hospital. She thought the resident was ""pretty low on her LOC (level of consciousness)."" -- The resident was interviewed at 1:25 p.m. on 07/26/11. She said she had had nose bleeds three (3) times, but this last had been the worst. She said she had had two (2) nose bleeds while here and one (1) at another nursing home. She said her shirt had been covered with blood when this happened. The resident said she was on a blood thinner when this happened, but she was not anymore. She said they had given her two (2) shots and it did not help so they had sent her to the hospital. At the hospital, they had put some things in her nose to stop the bleeding (she made a face as she spoke of this). She said ""he"" had two (2) needles in her arm. As she spoke about the needles, she gestured with each hand as though sticking something in the opposite arm. As she made this gesture, she became animated and grimaced. The resident related ""he"" had wanted her to stay, but she said she had told him she wanted to come back to the nursing home. ""He"" (according to the resident) said he had to do something with the needles, then she could go home. She said she had spots of blood down her shirt when tried to quantify the bleeding. On 07/27/11 at 9:30 a.m., the resident was interviewed again. The resident was asked about her nose (as she was documented as putting her finger in her nose causing very minor bleeding). She said they were putting some white stuff in her nose that helped - kept if from hurting. She said the doctor had told her her nose was a problem. She again said she had had nose bleeds three (3) times, but that last time was the only time she had had to go to the hospital. She again talked about the needles in her arms and repeated the same gestures she had made on 07/26/11. -- Record review revealed there was no physician's order for routine INRs. A nurse would contact the physician with the results of the test, and the physician would order a dosage change for the [MEDICATION NAME], if indicated. If the dosage changed or the physician wanted to recheck the INR, he or she would order another INR to be completed. -- The lab section of the resident's record was reviewed. The most recent PT/INR studies were as follows ((L) = low; (H) = high): (Date of lab - PT - INR - any notations made on the lab results) 04/05/11 - 15.3 - 1.4 (L) 04/13/11 - 13.8 - 1.2 (L) 04/18/11 - 16.2 - 1.6 (L) 05/03/11 - 16.5 - 1.6 (L) - ""On 4/18 INR 1.6 on 5.5 [MEDICATION NAME] 6 mg [MEDICATION NAME] Repeat PT/INR on 5/11/11"" (On 05/04/11, the physician order a PT/INR to be done on 05/11/11. The results of the 05/11/11 labs were not found.) 05/23/11 - 30.6 - 4.7 (H) - ""6 mg now hold [MEDICATION NAME] to recheck tomorrow 05/24/11"" 05/24/11 - 27.0 - 3.7 (H) - ""Hold [MEDICATION NAME] tonight PT INR 05/25/11"" 05/25/11 - 23.2 - 2.8 - ""Start 5 mg repeat INR Tuesday"" 05/31/11 - 14.6 - 1.4 (L) (On 06/01/11, the physician ordered a PT/INR to be done in three (3) days (on 06/04/11). The results of the 06/04/11 labs were not found.) 06/30/11 - 42.3 - 8.7 (H) (This elevated INR was well above previous results for which the physician had ordered the [MEDICATION NAME] held.) -- On the afternoon of 07/27/11, Employee #63 (a registered nurse - RN) was asked where additional lab reports might be found. She said she would check the resident's thinned records. Some of the missing reports were found and copies provided. At approximately 11:45 a.m. on 07/27/11, the director of nursing (DON) was informed that the resident had not had an INR between 05/31/11 and 06/30/11. On the morning of 07/28/11, the DON was asked to try to locate the reports for INRs that were to have been done on 05/11/11 and 06/04/11. She later reported the studies had not been done. -- Review of Resident #34's hospital records for 06/30/11 noted the following. - The ""Emergency Provider Record"" noted the time seen was 1700 (5:00 p.m.). Under ""onset / duration"" was written: ""continuous epistaxis x 8 hr. . . ."" Under the past history, ""previous nosebleeds"" and ""occasionally"" were circled. Her general appearance was noted as ""mild / moderate distress head atraumatic, sinus non-tender NOSE - nml (normal) inspection, dried blood, fresh clots, R & L (right and left) were circled. Active bleeding R/L & mod (moderate) were circled."" Her INR was noted to be 9.68. The clinical impression was: ""Epistaxis - anterior - [MEDICATION NAME] Toxicity"". The hospital documentation included a nursing assessment which noted the chief complaint was a nose bleed, elevated PT/PTT. Her blood pressures were charted every ten (10) minutes with the lowest recorded as 71/60. It was noted she had been given total of 10 mg Vitamin K IM at the nursing home. Her skin was listed as pale. Bleeding was noted of the right nares and her tongue had dried blood. The lab studies at the hospital were: 06/30/11 at 23:30: - WBC - 22.1 (reference range of 4.8 - 10.8) - PT - 48.9 - Critical high (reference range of 10.8 - 13.6) - INR - 9.63 - Critical high (reference range of 2.00 - 3.50) 07/01/11 at 3:15: - APTT - 51.6 - Critical high (reference range of 20.8 - 33.7) - [MEDICATION NAME] - 20.3 - High - INR - 2.19 While at the hospital, she was given 250 ml of normal saline bolus, and 10 ml of 1% [MEDICATION NAME] with epi ([MEDICATION NAME]). Nasal tampons were inserted, and she was given two (2) units of fresh frozen plasma (used at times to help the blood coagulate). -- A hospital record from 02/19/11 noted the resident had been sent to the hospital for altered mental status and shortness of breath. Her labs included an INR of 6.56 (high). The assessment and plan included: ""2. Supratherapeutic INR - unclear if this is from an improper medication dosage of due to another medication interaction. At this time no medication interactions can be found documented that would cause this. At this time we will hold her [MEDICATION NAME] doses and avoid other medications that could exacerbate her [MEDICATION NAME] therapy. We will check a daily PT and INR and monitor. At this time there is no indication of any active or subclinical bleeding, however, we will continue to monitor and give vitamin K if needed."" -- The PT/INR ordered on [DATE] to be done on 05/11/11 could not be located. When the lab was performed on 05/23/11, the INR was high and the [MEDICATION NAME] had to be held. The resident did not have an INR done from 05/31/11 until 06/30/11. The facility had failed to obtain an INR ordered on [DATE], to be done in three (3) days (06/04/11). The physician needed the results of the test to determine whether the dosage of [MEDICATION NAME] needed to be adjusted. Therefore, the [MEDICATION NAME] was not titered as had previously been done. Her INR became significantly elevated resulting in bleeding that did not respond satisfactorily to Vitamin K injections. Although the INR might have become elevated despite the lack of INRs and dosage adjustment, it would have lessened the chance of such a significant elevation. On 06/30/11, the resident developed a nose bleed. Based on what was learned through interviews with staff, the bleeding persisted for more than eight (8) hours. During this time, the physician was notified and ordered an injection of Vitamin K (used to reverse the effects of [MEDICATION NAME] ([MEDICATION NAME])). The resident continued to have a nose bleed. A second injection of Vitamin K was ordered and administered. The nose bleed continued and there was a concern about the resident's vital signs. She was transferred to the emergency room for further evaluation and treatment. In the emergency room , her nose was packed and she was given two (2) units of fresh frozen plasma (FFP). An INR done in the emergency room was 9.3. (Note: This resident was known to pick at her nose, and this may have caused the bleeding to occur initially, but it would not have been the cause of the bleeding to persist for hours.) (See also citation at F502.) .",2014-11-01
10915,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-07-27,441,F,1,0,E44N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of employee time records, and review of employee work releases, the facility failed to establish and maintain an infection control program to assure the prevention, to the extent possible, of the transmission of disease and infection. The facility failed to investigate an employee with a communicable disease (Shingles) to assure she was not contagious, to assure she was safe to work in the dietary department, and to assure effective infection control precautions were implemented, if needed. This practice had the potential to affect all facility residents. Facility census: 55. Findings include: a) On 07/27/11, an allegation that someone in the kitchen was working with a communicable disease (specifically Shingles) was investigated. At 10:00 a.m., interviews were conducted with the facility's administrator (Employee #14), dietary manager (DM - Employee #20), and the person responsible for infection control (Employee #54), who was also the director of nursing (DON). These persons recalled a dietary employee (Employee #66) whom they said stated she had Shingles. According to Employee #20, Employee #66 had been released to return to work on 07/12/11. Further interview revealed the facility did not make any inquiries regarding the employee's Shingles. The statement from the employee, that she had Shingles, was the only information the facility had regarding Employee #66 and a [DIAGNOSES REDACTED]. Facility staff did not even know whether the employee had actually been diagnosed with [REDACTED]. The DON confirmed she heard the employee had Shingles when Employee #66 called off on 07/09/11. The DON stated she had assisted in securing coverage for Employee #66's position on that date. The DON confirmed she had not made any inquiries of the employee regarding the Shingles, at any time, to assure the employee was not contagious and could safely work at the facility. The DM also confirmed she was told by the employee she had Shingles, but the DM had not made any inquiries regarding whether the employee was contagious and/or whether she was safe to work. On 08/02/11 at 12:45 p.m., a telephone conversation was held with Employee #66, the employee with Shingles. This person confirmed she had informed the DM she had Shingles. Employee #66 stated no one at the facility made any inquiries regarding whether or not she was contagious. The employee also stated she had not informed the physician of what type of work she did. The facility provided a return to work release for 07/08/11 and another return to work release for 07/12/11, but neither indicated whether or not restrictions were needed and/or if the employee was safe to work in the dietary department. The facility failed to make reasonable efforts to assure Employee #66 was not contagious after she reported she had Shingles, and failed to assure she was safe to work in the dietary department during the period of time the employee stated she had Shingles.",2014-11-01
10916,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,309,D,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, observation, medical record review, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being in accordance with the plan of care for one (1) of eight (8) residents observed who had orders for [MEDICATION NAME] medication patches. Resident #33 had a physician's orders [REDACTED]. Observations with a licensed practical nurse (LPN - Employee #99) - the LPN responsible for medication pass this day, on 07/12/11 at 8:30 a.m., found Resident #33 had a Nitro-Dur patch on her chest that was dated 07/11/11. Employee #99 stated the patch on the resident's chest dated 07/11/11 should have been removed in the evening on 07/11/11. The failure of nursing staff to remove the Nitro-Dur patch as ordered resulted in the resident receiving an excessive dose of this medication. Resident identifier: #33. Facility census: 97. Findings include: a) Resident #33 During a random interview on 07/11/11 at 3:00 p.m., a family member expressed a concern regarding how the facility was providing care for residents who received medication via patches that were applied externally. During this interview, the family member expressed a concern about finding excess patches on her resident. On 07/12/11 at 8:30 a.m., observations were made of eight (8) residents who were identified by the medication nurses as having [MEDICATION NAME] medication patches. Observations with the medication nurse (Employee #99) found Resident #33 had a Nitro-Dur patch in place on the chest upon examination. The medication nurse reported this patch should not have been found on the resident this morning, as the patch should have been removed the previous evening. Further observation of the medication patch found it was dated for 07/11/11; the medication nurse stated this patch had been applied on the morning of on 07/11/11 and should have been removed by the medication nurse on the evening of 07/11/11. Review of the physician's orders [REDACTED]. On in the a.m. (morning) and off in the p.m. (evening) and the patch was for Arthrosclerotic [MEDICAL CONDITION]."" During an interview with the director of nursing (DON - Employee #2) on 07/13/11 at 11:30 a.m., this finding and practice was brought to her attention. The DON acknowledged this practice should not have occurred and that this was a medication error. .",2014-11-01
10917,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,323,K,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on the review of incident / accident reports, medical record review, family interview, staff interview, policy review, review of staff inservice training records, personnel record review, observations, and review of the facility's emergency preparedness plan, the facility failed to provide adequate supervision while smoking to one (1) of two (2) residents who required the use of supplemental oxygen. On 07/03/11, Resident #10 was permitted to smoke while receiving oxygen from a portable oxygen tank via a nasal cannula; a lit cigarette ignited the oxygen resulting in severe facial burns to Resident #10 which required treatment at an out-of-state burn unit. Resident #10 had been assessed by the facility as requiring staff supervision while she smoked, and the individual assigned to provide this supervision on the morning of 07/03/11 was a receptionist. The receptionist was not on the list of staff whose departments were routinely assigned the responsibility for supervising resident smoke breaks, and there was no evidence the receptionist had received training on the dangers / hazards of smoking in the presence of oxygen. This practice placed Resident #10 in immediate jeopardy and presented the potential for more than minimal harm to the other four (4) residents and any staff members in the designated resident smoking area at the time of the occurrence. After the incident involving Resident #10 occurred on 07/03/11, the facility provided training to staff on how to extinguish residents who are on fire using a blanket, sheet, or other large covering (and NOT a fire extinguisher). Observation of the resident smoking area found the only device available to smother a fire was a fire extinguisher, which the policy specifically instructed staff to not use to smother fire on a resident. No large covering was readily available for use by staff if it were again necessary to smother fire on a resident. Although a fire blanket was available in a storage cabinet in the employee smoking area, a staff member would have to travel 228 feet from the resident smoking area to the fire blanket in the employee smoking area. For this reason, immediate jeopardy was determined to have been on-going since the incident on 07/03/11, with the potential to affect all residents who smoke. On 07/12/11 at 12:40 p.m., the administrator was informed that immediate jeopardy had been present at the time of the incident on 07/03/11 and was on-going. During a subsequent meeting with the administrator on 07/12/11 at 2:50 p.m., the administrator provided evidence of having implemented the following actions steps: (1) an addendum to the facility's resident smoking policy to include staff training on the prohibition against the presence of oxygen within 5 feet of any smoking, staff training on how to extinguish a fire utilizing the extinguisher and fire blankets, and staff training on how to safely monitor and assist residents with smoking (including but not limited to the possible need for smoking aprons and assisting residents to properly extinguish materials as needed); and (2) relocation of resident smoking to the area previously designated for employee smoking, where the fire blanket in a storage cabinet was readily available for use in an emergency. The survey team verified resident smoking was moved to the area where the fire blanket was located and that employees were inserviced in its use, and a randomly selected staff member was able to demonstrate the proper use of the fire blanket. At 3:25 p.m. on 07/12/11, the nursing home administrator was notified the immediate jeopardy had been removed with no deficient practice remaining with respect to these concerns. Resident identifier: #10. Facility census: 97. Findings include: a) Resident #10 Review of the facility's incident / accident reports, on 07/11/11, found a report dated 07/11/11 (and identified as a late entry for 07/03/11 at 10:10 a.m.), providing the following description of the incident (quoted as written): ""Res (resident) was taken out of smoke /c (with) staff member & oxygen NC (nasal cannula) remained on resulting in burn to lower lip, (L) (left) cheek, & RLE (right lower extremity). Entire area around nose & mouth noted to be black in color. Resident immediately given cold washcloth & pain medication then 911 was notified of need for transport. Staff remained /c resident til squad arrived."" Review of Resident #10's medical record found a late entry nursing note dated 07/03/11 at 10:26 a.m., stating: ""Resident was taken out to smoke with staff member & oxygen remained on resulting in cigarette catching on fire. Entire area around mouth & nose noted to be black, burn noted to bottom lip as well as right lower leg. Unable to assess any other injuries r/t (related to) blackened area around mouth & nose. ..."" A nursing note, dated 07/05/11 at 22:15 (10:15 p.m.), revealed the resident was readmitted to the facility from a hospital burn center. A nursing assessment of the resident's facial burns stated,""... Large 2nd degree burn noted to facial area around mouth. Lips edematous with blistered areas. Slight facial edema noted. Denies any difficulty swallowing at present. 2 small circular burns noted to left forearm and 3 small burns noted to right forearm. 1 small circular burn to top of right foot and 1 medium sized burn to top of right foot. ..."" Further review of the medical record found Resident #10 was a [AGE] year old female with medical [DIAGNOSES REDACTED]. The resident was currently receiving hospice services. Both before and after her hospitalized from [DATE] through 07/05/11, she had physician's orders [REDACTED]. -- During an interview on 07/11/11 at 2:30 p.m., the resident's daughter reported Resident #10 had been declared to lack capacity to make medical decisions and she was the resident's medical power of attorney representative (MPOA). Random staff interviews, conducted during the course of this survey, found the resident was alert, verbal and oriented most of the time, but she had some confusion at intervals. Review of a smoking evaluation, completed on 06/01/11, found Resident #10 was evaluated as having dementia, poor memory, and being unable to demonstrate knowledge of the location of the designated smoking area. The evaluation also stated she required supervised smoking. -- Review of the facility's internal investigation into the above incident found the following: In a statement dated 07/03/11, the receptionist (Employee #106) wrote (quoted as written): ""I (name of Employee #106), was asked to go back and sit with (Resident #10) due to being short on staffing. (Resident #10) had her breakfast and after she was done eating she asked to go out and have a cigarette. I turned her call light on and (Employee #117, a nursing assistant) came in and assisted (Resident #10) with getting dressed. As I was escorting (Resident #10) down the hallway to get her cigarettes from the nurse, (Resident #10) requested that her oxygen be put back on. When we arrived to (Employee #63, a licensed practical nurse)'s cart she placed the oxygen back onto (Resident #10) and turned the setting on 3. She then handed me two cigarettes and I took (Resident #10) onto the patio. I lit the first cigarette for (Resident #10) and once she was finished with that cigarette, she asked if she could smoke her second one, I replied yes. I lit the second cigarette and about halfway through, the cigarette burst into flames and caught (Resident #10)'s O2 (oxygen) tubing on fire. Immediately, I ripped the tubing off of (Resident #10) and threw it to the ground and multiply stepped on it to put it out. I ran (Resident #10) back into the building and told (Employee #99, a registered nurse) which was standing outside of room 207. She then motioned (Employee #63) to come over. (Resident #10) was then escorted to her room and aides applied cold washcloths / ice to (Resident #10)'s face."" - In a statement dated 07/05/11, the licensed practical nurse (LPN) who was assigned to provide care for this resident on 07/03/11 on the 7-3 shift (Employee #63) wrote that Resident #10 had required one-to-one supervision on this day to prevent falls with injury. Her statement contained the following (quoted as written): ""... I then asked a CNA (certified nursing assistant) to sit with her to give her one on one to prevent a fall with injury. CNA then proceeded to provide one on one care. I explained situation to the weekend manager who stated she would attempt to find someone who wasn't a CNA to provide one on one care so that this CNA could continue to assist on the floor as previously assigned. The receptionist, (name of Employee #106), then provided one on one care as requested by manager. When resident was finished with breakfast she then asked to go smoke a cigarette. The CNA assisted resident with toileting & dressing & assisted her into her w/c (wheelchair). (Name of Employee #106) then wheeled her to my cart in the hall where I was doing my med pass. She asked me to turn on her oxygen, which I did due to her SOB (shortness of breath) from ADLs (activities of daily living). When a resident is on continuous oxygen, my nursing judgment tells me to turn on the oxygen. She then asked for 2 cigarettes which are kept locked up on med cart. I handed her the cigarettes as requested. I then proceeded to continue my med pass. A little while later I was pulled out of a resident's room to assess (Resident #10) who had been injured while outside smoking. ..."" - Review of the facility's follow-up summary (which was not dated) found the following (quoted as typed): ""... Upon completing the investigation, it has been determined that the LPN, (Employee #63), failed to act prudently which resulted in injury to this resident. ""Per (Employee #63)'s statement and interview, she stated that the facility receptionist had asked her to turn on (Resident #10)'s oxygen. She stated that she did so due to the resident being short of breath from completing her ADL's. The receptionist then asked (Employee #63) for 2 cigarettes which were kept locked up on the medication cart. (Employee #63) then stated that she proceeded to continue her medication pass. She indicated during interview that she assumed the oxygen would be removed prior to the resident smoking. The receptionist should not adjust, apply or remove oxygen from a resident. Therefore, (Employee #63), failed to assure that oxygen would not be in use while this resident was smoking. ..."" -- An interview was conducted with a registered nurse (RN - Employee #71) at 4:15 p.m. on 07/11/11. She relayed that, on a previous occasion in April or May 2011, she had observed Resident #10 in the employee smoking area while being supervised by a nursing assistant; her nasal cannula in place and her oxygen on. Approximately eight (8) staff members were smoking in that area while Resident #10 was using oxygen, and Resident #10 was seated approximately 3 feet away from the nearest smoker. Neither the nurse aide nor any of the other staff members present removed Resident #10 from the area. When asked if she reported this incident, she conveyed that she took care of the situation and did not report it. -- Review of the facility's resident smoke break schedule (dated 02/22/11) revealed the following (quoted as typed with handwritten corrections): ""To all staff & residents: ""The following schedule will be effective for all Residents that smoke starting 3/1/2011 9:30 am Housekeeping to Supervise 11:00 am Activities to Supervise 1:30 pm Activities to Supervise 5:00 pm Housekeeping to Supervise 8:00 pm Nursing to Supervise ""The schedule is to be followed by all staff and residents. The resident is to be able to smoke two cigarettes for each break period. Thanks for all your cooperation in setting this plan in place."" The receptionist was not employed in any of the departments that routinely provide supervision to residents during smoke breaks. -- Review of Employee #106's personnel file revealed that, although she had received basic information during general orientation, there was no mention in the Fire Safety portion of the orientation packet that specifically advised this non-nurse of any prohibition against smoking near oxygen. -- Review of the facility's inservice records revealed the last time any facility-wide training had been provided on the emergency preparedness plan (including fire and safety rules and prevention) was in May 2010. Review of the list of employees who attended this training found Employee #106 was not among them. An interview with the administrator, on 07/13/11 at 10:30 a.m., revealed this in-service should have been provided annually to all employees according to facility policy. (See also citation at F518.) -- Immediate jeopardy existed at the time of the incident involving Resident #10 on the morning of 07/03/11, due to the fact that the facility assigned a non-nursing employee (who received no training on the dangers / hazards of smoking around oxygen) to supervise a resident (who had a physician's orders [REDACTED]. --- b) Review of information provided by the facility, identifying action steps taken after the incident involving Resident #10 on 07/03/11, revealed the following staff inservices were provided: - On 07/03/11, 07/04/11, 07/05/11, 07/06/11, and 07/08/11 - Resident Smoking Policy (with an addendum specifically stating do not take O2 tanks into the smoking area) - On 07/05/11, 07/06/11, and 07/08/11 - Resident Smoker Audit Tool - On 07/05/11, 07/06/11, 07/07/11, 07/08/11, and 07/11/11 - Oxygen Therapy and Hazards Petroleum-based Products (with attached policies titled ""11.8 Liquid Oxygen System"" and ""11.9 Nasal Cannula"") - On 07/05/11, 07/06/11, 07/07/11, 07/08/11, and 07/11/11 - Emergency Care of Patient on Fire (with attached policy titled ""6.4 Burns: Fire / Heating Source"") - On 07/06/11, 07/07/11 and 07/11/11 - New Resident Smoking Area -- Review of the facility's policy titled ""6.4 Burns: Fire / Heating Source"" (dated 01/01/04), found the following: ""1. Stop the burning process: ""1.1 If customer is on fire, smother fire with sheet, blanket, or other large covering. Shield the customer's face and pat away from the fire. Keep head outside covering. Call out for help. Instruct to call 911. ""1.1.1 CAUTION: DO NOT use a fire extinguisher on a customer. ..."" -- Observations of the resident smoking area in the courtyard, on the afternoon of 07/11/11 and the morning of 07/12/11, found residents continued to smoke in that area, but no large covering (like a fire blanket) was available for use if a resident were to catch on fire. The only device available for smothering a fire was a fire extinguisher, which the facility's policy specifically directs staff to NOT use on a person. -- Observation of the employee smoking area (which, based on staff interviews, had also been used by residents when smoking) found a fire blanket in a storage cabinet was available at the entrance to the employee smoking area. The travel distance between the smoking area in use by residents on 07/03/11 and to the fire blanket stored in a cabinet in the smoking area in use by employees on 07/03/11 was 228 feet, as reported by the maintenance director (Employee #120) during a telephone interview on 07/28/11. -- On 07/12/11 at 12:40 p.m., the facility's administrator was informed that immediate jeopardy was present at the time of the incident involving Resident #10 and was on-going, due to the lack of availability appropriate equipment to extinguish a fire on a person in the resident smoking area, as identified in the facility's policy. --- c) During a subsequent meeting with the administrator on 07/12/11 at 2:50 p.m., the administrator provided evidence of having implemented the following actions steps: (1) an addendum to the facility's resident smoking policy to include staff training on the prohibition against the presence of oxygen within 5 feet of any smoking, staff training on how to extinguish a fire utilizing the extinguisher and fire blankets, and staff training on how to safely monitor and assist residents with smoking (including but not limited to the possible need for smoking aprons and assisting residents to properly extinguish materials as needed); and (2) relocation of resident smoking to the area previously designated for employee smoking, where the fire blanket in a storage cabinet was readily available for use in an emergency. The survey team verified that resident smoking was moved to the area where the fire blanket was located and that employees were inserviced in its use, and a randomly selected staff member was able to demonstrate the proper use of the fire blanket. At 3:25 p.m. on 07/12/11, the nursing home administrator was notified the immediate jeopardy had been removed with no deficient practice remaining with respect to these concerns. --- Part II -- Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, by failing to secure against unauthorized access a clean utility room in which potentially hazardous substances were stored. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) During the initial tour of the facility upon entrance on 07/11/11 at 2:00 p.m., observation found the door to the clean utility room standing wide open. An inspection of this room found tubes of zinc oxide, hydrocortisone cream, bottles of hydrogen peroxide, bottles of isopropyl alcohol, tubes of Calmoseptine ointment, sterile dressing supplies, and sterile indwelling catheter supplies. The room was accessible to visitors and wandering residents. The director of nursing (DON) was notified of this accident hazard at 2:20 p.m. The facility subsequently installed a lock on the door to prevent unauthorized access. .",2014-11-01
10918,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,518,F,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's policies and inservice records and staff interview, the facility failed to inservice employees in emergency preparedness annually as indicated in the facility policy titled 1.37 Emergency Preparedness with an effective date of 04/01/03. Review of the facility's inservice records disclosed the last emergency / disaster preparedness inservice for employees was provided in May 2010, and the administrator confirmed the emergency preparedness inservice had not been presented to employees annually as the policy indicated. Failure of the facility to train all staff on the hazards of having open flames around oxygen resulted in Resident #10 sustaining severe [MEDICAL CONDITION] smoking a cigarette while receiving supplemental oxygen via a nasal cannula. (At the time of this occurrence, the staff member who was providing supervision while Resident #10 was smoking had not received any such training.) This practice of not training staff annually on the facility's emergency / disaster preparedness plan has the potential to affect all residents. Findings include: a) Review of the facility's inservices record for employees in 2010 and 2011 found the facility had not conducted their annual training on the Emergency Preparedness Plan for all employees, as required by their policy titled ""1.37 Emergency Preparedness"" (dated 04/01/03). Review of this emergency plan found the following topics to be covered: ""Accident Prevention / Safety and Fire and Safety Rules and Prevention"". According to the facility's inservice records, the last time the facility had provided staff training on emergency preparedness covering the topics of accident prevention and fire and safety rules and prevention was in May 2010. During an interview on 07/13/11 at 10:30 a.m., the facility's administrator (Employee #1) confirmed the emergency preparedness inservice training had not been provided annually for all employees as the facility's policy required. Failure of the facility to train all staff on the hazards of having open flames around oxygen resulted in Resident #10 sustaining severe [MEDICAL CONDITION] smoking a cigarette while receiving supplemental oxygen via a nasal cannula. At the time of this occurrence, the staff member who was providing supervision while Resident #10 was smoking had not received any such training. (See also citation at F323.)",2014-11-01
10919,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,225,D,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure all allegations of neglect were reported immediately to the administrator of the facility and to other officials in accordance with State law. On 07/03/11, Resident #10 suffered [MEDICAL CONDITION] her face while smoking while receiving oxygen through a nasal cannula. Resident #10 required supervision while smoking, and a receptionist with no nursing credentials or training related to the dangers of smoking while utilizing oxygen was entrusted with her care when the resident's oxygen ignited. Prior to 07/03/11, a registered nurse (RN - Employee #71) witnessed Resident #10 in a designated smoking area while receiving oxygen via nasal cannula. The resident was being supervised by a nurse aide at that time. Approximately eight (8) staff members were smoking in that area while Resident #10 was using oxygen, and Resident #10 was seated approximately 3 feet away from the nearest smoker. Neither the nurse aide nor any of the other staff members present removed Resident #10 from the area. Employee #71 failed to report this witnessed act of neglect as required. This deficient practice had the potential to affect one (1) of two (2) residents who are active smokers and who utilize supplemental oxygen. Resident identifier: #10. Facility census: 97. Findings include: a) Resident #10 Review of facility documents found an incident which occurred on 07/03/11, in which Resident #10 was grievously injured while smoking with her oxygen on. Resident #10 suffered severe [MEDICAL CONDITION] required treatment in an out-of-state burn unit. Further review found the resident was not permitted to smoke unsupervised. On 07/03/11, a licensed practical nurse (LPN - Employee #63) turned the resident's oxygen on and handed two (2) cigarettes to the receptionist to take the resident out to smoke. While lighting the resident's cigarette, the tubing on the nasal cannula burst into flames, causing severe injury to the resident. An interview was conducted with a registered nurse (RN - Employee #71) at 4:15 p.m. on 07/11/11. She relayed that, on a previous occasion in April or May 2011, she had observed Resident #10 in the employee smoking area while being supervised by a nursing assistant; her nasal cannula in place and her oxygen on. Approximately eight (8) staff members were smoking in that area while Resident #10 was using oxygen, and Resident #10 was seated approximately 3 feet away from the nearest smoker. Neither the nurse aide nor any of the other staff members present removed Resident #10 from the area. When asked if she reported this incident, she conveyed that she took care of the situation and did not report it. .",2014-11-01
10920,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,441,F,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, policy review, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infection. Staff entering rooms occupied by residents in contact isolation did not don appropriate personal protective equipment or perform hand hygiene when indicated, and housekeeping staff did not utilize the appropriate cleaning solution when cleaning isolation rooms occupied by residents with Clostridium difficile. This deficient practice had the potential to affect all residents currently residing in the facility. Facility census: 97. Findings include: a) During random observations of the resident environment on 07/12/11 at 10:00 a.m., a nursing assistant (NA - Employee #128) was observed to enter a resident's room who was in contact isolation due to a Clostridium difficile (C-Diff) infection. Employee #128 did not don personal protective equipment (PPE) prior to entering the room to replace a pillow case, nor did she wash her hands after exiting the room. She then crossed the hallway and accessed the clean linen on the clean linen cart. On 07/13/11 at 2:00 p.m., a physical therapy assistant (PTA - Employee #127) was observed to be sitting on the unoccupied bed of a resident's who was placed in contact isolation due to a[DIAGNOSES REDACTED] infection. Employee #127 did not have on PPE to prevent contamination of his hands and clothing, and he did not wash his hands prior to exiting the contact isolation room. - Review of the facility's policy entitled ""3.1 Contact Precautions"" (revision date 09/01/10), in Section 4, found the following information: ""Use barrier precautions for all contact with patient and patient's immediate environment. 4.1 Wear gown and gloves when entering the room... 4.4 Remove and bag gown and gloves and wash hands upon exiting the room."" - An interview with the infection control registered nurse (RN - Employee #5) following each of these observations elicited that the individuals did not provide care in accordance with the facility's infection control policies. Employee #5 provided immediate inservice education to the individuals and their respective departments. -- b) During a random observation, a housekeeping aide (Employee #113) was observed to prepare to clean an isolation room of a resident in contact isolation due to a[DIAGNOSES REDACTED] infection. Employee #113 was interviewed at 10:10 a.m. on 07/12/11. When asked what cleaner he utilized for the surface, floor and commode of this particular room, he reported he utilized the facility's standard cleaning products. When specifically asked about the procedure for cleaning the commode, he stated he utilized a commode brush located on his cart, then rinsed it out and used it in other rooms. - An interview with the housekeeping supervisor (Employee #6), on 07/12/11 at 10:15 a.m., confirmed the cleaning products utilized by the housekeeping staff were not effective in killing[DIAGNOSES REDACTED] spores. Employee #6 acknowledged the facility did not utilize a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach) solution when cleaning contact isolation rooms potentially contaminated with[DIAGNOSES REDACTED] spores. - Review of the facility policy 2.1 entitled ""Cleaning and Disinfecting"" (revised 09/01/10) found, in Section 5, the following requirements: ""5. Clean environmental surfaces, floors, walls, furniture using EPA approved, hospital grade disinfectant according to schedule and need. For patients with [DIAGNOSES REDACTED]icile or norovirus use a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach)."" .",2014-11-01
10921,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,490,K,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, staff interviews, and review of the facility's emergency / disaster preparedness records, the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and emergency / disaster training, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable concerning the dangers / hazards associated with resident smoking, placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice, and presented the potential for more than minimal harm to all residents related to the facility's failure to appropriately train employees in emergency preparedness. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 97. Findings include: a) Findings of immediate jeopardy Review of facility documents found that, on 07/03/11, Resident #10 suffered severe [MEDICAL CONDITION] treatment in an out-of-state burn unit. Resident #10 was supervised while smoking by a staff member who had not been trained in the hazards / dangers of smoking while utilizing oxygen. The staff member lit Resident #10's cigarette while the resident was receiving supplemental oxygen via a nasal cannula. The oxygen was ignited by the lit cigarette, which caused grievous injury to Resident #10. Observation of the area designated for resident smoking, on 07/12/11, noted the absence of a readily available device to smother flames (e.g., smoking blanket). Further observation noted an unsecured fire extinguisher sitting on the concrete walk by a resident's chair who was smoking. An inspection of the tag attached to the fire extinguisher noted no documentation of an inspection for proper working order since February 2011. The administrator was informed at 12:40 p.m. on 07/12/11 that the failure to provide safety devices in the resident smoking area, failure to assure adequate staff training, and failure to develop policies related to staff training regarding safety measures to be employed during resident smoking placed more than an isolated number of residents in immediate jeopardy of injury or death. (See also citation at F323.) -- b) Infection control 1. During random observations of the resident environment on 07/12/11 at 10:00 a.m., a nursing assistant (NA - Employee #128) was observed to enter a resident's room who was in contact isolation due to a [MEDICAL CONDITIONS] infection. Employee #128 did not don personal protective equipment (PPE) prior to entering the room to replace a pillow case, nor did she wash her hands after exiting the room. She then crossed the hallway and accessed the clean linen on the clean linen cart. On 07/13/11 at 2:00 p.m., a physical therapy assistant (PTA - Employee #127) was observed to be sitting on the unoccupied bed of a resident's who was placed in contact isolation due to a [MEDICAL CONDITION] infection. Employee #127 did not have on PPE to prevent contamination of his hands and clothing, and he did not wash his hands prior to exiting the contact isolation room. - Review of the facility's policy entitled ""3.1 Contact Precautions"" (revision date 09/01/10), in Section 4, found the following information: ""Use barrier precautions for all contact with patient and patient's immediate environment. 4.1 Wear gown and gloves when entering the room... 4.4 Remove and bag gown and gloves and wash hands upon exiting the room."" - An interview with the infection control registered nurse (RN - Employee #5) following each of these observations elicited that the individuals did not provide care in accordance with the facility's infection control policies. Employee #5 provided immediate inservice education to the individuals and their respective departments. -- 2. During a random observation, a housekeeping aide (Employee #113) was observed to prepare to clean an isolation room of a resident in contact isolation due to a [MEDICAL CONDITION] infection. Employee #113 was interviewed at 10:10 a.m. on 07/12/11. When asked what cleaner he utilized for the surface, floor and commode of this particular room, he reported he utilized the facility's standard cleaning products. When specifically asked about the procedure for cleaning the commode, he stated he utilized a commode brush located on his cart, then rinsed it out and used it in other rooms. - An interview with the housekeeping supervisor (Employee #6), on 07/12/11 at 10:15 a.m., confirmed the cleaning products utilized by the housekeeping staff were not effective in killing [MEDICAL CONDITION] spores. Employee #6 acknowledged the facility did not utilize a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach) solution when cleaning contact isolation rooms potentially contaminated with [MEDICAL CONDITION] spores. - Review of the facility policy 2.1 entitled ""Cleaning and Disinfecting"" (revised 09/01/10) found, in Section 5, the following requirements: ""5. Clean environmental surfaces, floors, walls, furniture using EPA approved, hospital grade disinfectant according to schedule and need. For patients with [DIAGNOSES REDACTED]icile or norovirus use a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach)."" -- c) Emergency / Disaster Preparedness Review of the facility's inservices record for employees in 2010 and 2011 found the facility had not conducted their annual training on the Emergency Preparedness Plan for all employees, as required by their policy titled ""1.37 Emergency Preparedness"" (dated 04/01/03). Review of this emergency plan found the following topics to be covered: ""Accident Prevention / Safety and Fire and Safety Rules and Prevention"". According to the facility's inservice records, the last time the facility had provided staff training on emergency preparedness covering the topics of accident prevention and fire and safety rules and prevention was in May 2010. During an interview on 07/13/11 at 10:30 a.m., the facility's administrator (Employee #1) confirmed the emergency preparedness inservice training had not been provided annually for all employees as the facility's policy required. Failure of the facility to train all staff on the hazards of having open flames around oxygen resulted in Resident #10 sustaining severe [MEDICAL CONDITION] smoking a cigarette while receiving supplemental oxygen via a nasal cannula. At the time of this occurrence, the staff member who was providing supervision while Resident #10 was smoking had not received any such training. (See also citation at F323.)",2014-11-01
10922,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2011-07-13,492,D,1,0,YYWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of WV Legislative Rule 19-10-3.9, and staff interview, the registered nurse (RN) serving as the director of nursing (DON) failed to report unsafe nursing practice. Resident #10 sustained severe burn injuries when smoking while utilizing oxygen. A licensed practical nurse (LPN - Employee #63) turned Resident #10's oxygen on and gave an untrained, unlicensed, staff member cigarettes to take the resident to smoke. The DON did not report this unsafe nursing practice to the LPN Licensing Board in accordance with rules and regulations governing the practice of registered nursing. This deficient practice had the potential to affect two (2) of two (2) residents who were active smokers and utilized oxygen. Facility census: 97. Findings include: a) Review of facility documents found Resident #10 sustained severe [MEDICAL CONDITION] smoking while utilizing oxygen on 07/03/11. Further review found an LPN (Employee #63) turned Resident #10's oxygen on and then provided two (2) cigarettes to the facility's receptionist to take the resident to smoke. The facility could provide no evidence that this receptionist had received training in the dangers of smoking while utilizing oxygen. Review of the facility's self-reports of abuse and neglect found no evidence that the RN serving as the DON reported this unsafe nursing practice by the LPN to her licensing board. Review of WV Legislative Rule 19-10-3.9 found the following language: ""The registered professional nurse shall report unsafe nursing practice to the Board and unsafe practice conditions to recognized legal authorities. ..."" An interview with the DON, on the afternoon of 07/14/11, elicited that no report of the LPN had been made to the LPN Licensing Board by this RN. .",2014-11-01
10923,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,278,D,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the minimum data set (MDS), and staff interview, the facility failed to provide an assessment that accurately reflected the health / functional status of one (1) of five (5) sampled residents. Resident #200's MDS did not reflect the presence of an indwelling urinary catheter. This failure resulted in the absence of goals and interventions for the care and monitoring of the device being included in the care plan. (See F279 for further details.) Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Review of the medical record found Resident #200 was admitted to the facility on [DATE] with an indwelling catheter for urinary drainage. Review of the admission MDS, with an assessment reference date (ARD) of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the intake / output records for Resident #200 noted that facility staff did not record the amount of urine put out via the indwelling catheter. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. .",2014-11-01
10924,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,279,D,1,0,34ZP11,"**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 which included measurable objectives and timetables to meet the medical and nursing needs of one (1) of five (5) sampled residents. Due to the failure to accurately complete the minimum data set (MDS), the care plan for Resident #200 was devoid of interventions related to the use of an indwelling urinary catheter. (See F278 for further details). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Review of the medical record found Resident #200 was admitted to the facility on [DATE] with an indwelling urinary catheter. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. .",2014-11-01
10925,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,502,D,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain ordered laboratory services to meet the needs of one (1) of five (5) sampled residents. The facility failed to obtain an ordered Hgb A1c test for Resident #200 following a blood glucose result of 265 mg/dl (normal range 74 gm/dl to 106 gm/dl). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received insulin injections of 30 units of [MEDICATION NAME]75/25 in the morning and 10 units of [MEDICATION NAME]in the evenings. Review of a complete blood count (CBC), ordered by the physician on 11/12/10, found the resident's glucose was 265mg/dl (with a normal range for this laboratory of 56 - 99 mg/dl). The nurse practitioner was notified of the report and ordered an Hgb A1c test. A nursing note, written on 11/13/10 at 7:26 a.m., documented the following: ""Hgb A1c No lab pick up on Saturdays."" Further review of the medical record found no evidence that the facility obtained this ordered test. On 12/06/10, the resident was found unresponsive and transported to an acute care facility. A blood test conducted upon admission found the resident's blood glucose was 886 mg/dl. He was diagnosed with [REDACTED].",2014-11-01
10926,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,224,G,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide necessary care and services to avoid physical harm for one (1) of five (5) sampled residents. The facility failed to appropriately monitor Resident #200's glucose levels, failed to assess and monitor a reddened area on the resident's penis, and failed to assess and monitor this resident's intake and output. Resident #200 was admitted to the hospital on [DATE], totally unresponsive, with [DIAGNOSES REDACTED]. Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 1. Record review revealed Resident #200 was an [AGE] year old white male admitted to this facility on 11/09/10 with [DIAGNOSES REDACTED]. Review of the history and physical, completed by his treating physician on 11/15/10 documented, the resident as being alert and oriented x 4. Review of the admission orders [REDACTED]. Further review found no orders for assessment of the resident's blood glucose levels. - Review of facility policy entitled ""Nursing Care of the Adult Diabetes Mellitus Resident"" (revised 05/01/06) found, under the section entitled ""Purpose"", the following language: ""... 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 3. Recognize, assist and document the treatment of [REDACTED]. The section entitled ""General Guidelines"" contained the following language: ""If you observe a diabetic resident or is a diabetic resident complains of any of the following symptoms, report it to the Unit Chare Nurse immediately. [MEDICAL CONDITION] d. malaise (appears tired)... b. lethargy (drowsiness)..."" The policy did not provide instructions to the charge nurse for what interventions to provide should the above symptoms be observed or reported. - Review of a complete blood count (CBC) laboratory test from 11/12/10 that the resident's glucose was 265 mg/dl. The physician ordered an Hgb A1c test. The medical record found no evidence this ordered test was provided. A nursing note, written on 11/13/10, documented the following: ""Hgb A1c No lab pick up on Saturdays."" There was no subsequent documentation in the record to indicate the ordered test was obtained. (See F502 for further details.) - Review of the facility's documentation of the resident's meal intake found the resident consumed no food from the noon meal on 12/04/10 through the noon meal on 12/06/10. The medical record contained no evidence the resident's glucose level was checked at any time during this time period. - Review of the nursing notes found an entry 11/30/10 recorded at 1:18 p.m. which documented that therapy staff reported that ""resident is sleeping more than usual"". The medical record contained no evidence the physician was notified of this sign / symptom of [MEDICAL CONDITION], nor that the resident's blood glucose was assessed. Further review found a nursing note, written on 12/06/10 at 11:46 a.m. which documented the following (quoted verbatim): ""patient is lethargic today. not following instructions... not participating well in therapy today"". The medical record contained no evidence that the physician was immediately notified of these signs / symptoms of [MEDICAL CONDITION], nor did the record contain evidence that the resident's glucose was assessed. There was no evidence that nursing staff monitored the resident's condition until he was found, at approximately 5:14 p.m. on 12/06/10, with a decreased level of consciousness and an inability to respond to staff when spoken to. The resident was transported to an acute care facility at approximately 5:30 p.m. on 12/06/10. - Review of the medical records from the acute care facility found the resident was nonresponsive upon arrival at the emergency room . Subsequent laboratory testing found the resident's blood glucose level was of 886 gm/dl (normal range 74 gm/dl to 106 gm/dl), a blood urea nitrogen (BUN) of 115 mg/dl (normal range 7 mg/dl to 18 mg/dl). He was diagnosed with [REDACTED]. Review of the admission and history by the acute care physician found the following statement: ""The nursing home could not find a record of his blood sugars."" -- 2. Review of the medical record found a nursing note, written at 12:03 p.m. on 11/24/10, documenting: ""Patient states his 'penis area' is red."" The nurse informed the nurse practitioner, who ordered [MEDICATION NAME] 200 mg every day for seven (7) days. Review of the Medication Administration Record [REDACTED]. Further review of the record found no evidence to reflect that nursing staff assessed or monitored the site following the initial resident complaint on 11/24/10. Review of nursing notes from the acute care facility, to which the resident was transferred on 12/06/10, found the following: ""Patient has purulent drainage noted from penis."" -- 3. Review of the medical record found Resident #200 had an indwelling urinary catheter present upon admission to the facility on [DATE]. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. (See also citations at F278 and F279.) Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. In addition to being indicative of impaired renal function, an elevated BUN is indicative of poor hydration status. Monitoring of fluid intake and output would have afforded the opportunity for early identification of a state of fluid imbalance. .",2014-11-01
10927,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,157,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the physician when a resident's fingerstick blood glucose level was elevated, in accordance with the physician's orders [REDACTED]. Resident #87 had a physician's orders [REDACTED]."" The result of the fingerstick on 09/05/11 was 314, and there was no evidence to reflect staff notified the physician of this elevated result. This practice affected one (1) of seventeen (17) sampled resident. Resident identifier: #87. Facility census: 98. Findings include: a) Resident #87 Review of the medical record for Resident #87 disclosed a physician's orders [REDACTED]. This order was given to change the parameters by which the doctor was to be notified. The prior order, dated 08/01/11, specified to notify the doctor if the fingersticks were below 60 ml/dl or over 200 ml/dl. Further record review disclosed that, on 09/05/11 at 6:00 a.m., the result of the resident's fingerstick blood sugar was 314 mg/dl. There was no evidence to reflect staff notified the physician of this elevated result, as specified in his order. During an interview with the administrator on 09/07/11 at 3:00 p.m., she reported that she questioned the nurses about this, and she verified that staff did not notify the doctor of this elevated blood sugar as specified in the physician's orders [REDACTED]. .",2014-11-01
10928,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,309,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care for diabetic residents as ordered by the physician for three (3) of fourteen (14) sampled residents who were diabetic. The facility failed to administer Resident #68's insulin as ordered by the physician the day following her admission to the facility. Resident #3's medication was not administered as ordered by the physician, and there was no evidence in the medical record to indicate why this medication was not administered. The physician was not notified of an elevated blood sugar of 314 mg/dl for Resident #87 as directed in the physician's orders [REDACTED]. The facility's failure to follow the physician's orders [REDACTED]. Facility census: 98. Findings include: a) Resident #68 According to the nursing notes, this resident was admitted on [DATE] and arrived at the facility at 11:15 p.m. Her [DIAGNOSES REDACTED]. There was no evidence the resident received the morning dose of 20 units of [MEDICATION NAME] 70/30 Insulin as ordered at 0630 (6:30 a.m.) on 09/06/11. The resident's fingerstick at 1130 (11:30 a.m.) on 09/06/11 was 215 mg/dl. This was then repeated at 4:30 p.m., and her fingerstick blood sugar was 132 mg/dl. She then received her [MEDICATION NAME] 70/30 insulin as ordered at 4:30 p.m. During an interview with the administrator on 09/07/11 at 3:15 p.m., she was questioned about this medication. She called the nurse at home at that time and verified that this medication was not administered that morning at 6:30 a.m. on 09/06/11, because it had not arrived from the pharmacy. The administrator also verified there was no evidence to reflect staff notified the physician that this medication was not available and was not administered as ordered. -- b) Resident #3 Record review revealed this resident had multiple medical conditions including [MEDICAL CONDITION], she was receiving [MEDICAL TREATMENT] three (3) times a week, and she has a [DIAGNOSES REDACTED]. This resident's physician orders, when reviewed, revealed an order for [REDACTED].) This resident's Medication Administration Record [REDACTED]""MNA"", meaning ""medication not available"" according to the code reference for the MAR. During an interview with the administrator on 09/08/11 at 3:00 p.m., she stated she talked to the nurse responsible for this entry (Employee #92), and the nurse said she must have hit the incorrect button - that this coding error incorrectly indicated the medication was not available. The administartor further reported the nurse said her blood sugar was low, which was why the [MEDICATION NAME] was not given. However, the administrator could not locate the results of the fingerstick that indicated the resident's blood sugar was low. Record review verified the nurse responsible for the ""MNA"" entry was Employee #92 (her initials were on the MAR). Employee #92, when interviewed on 09/07/11 at 4:00 p.m., stated she holds the insulin for this resident if her fingerstick is below 100 mg/dl. She stated Resident #3 ""bottoms out"" if her blood sugar is that low and the insulin is given. She reported that, on the day in question (08/29/11), her fingerstick results had been 99 mg/dl, so she did not administer her 9:00 a.m. insulin. There was no evidence to reflect this nurse notified the physician that the scheduled dose of [MEDICATION NAME] was not administered, and there was no record of the blood sugar result (99 mg/dl, as reported by Employee #92) at the time the medication was held. -- c) Resident #87 Review of the medical record for Resident #87 disclosed a physician's orders [REDACTED]. This order was given to change the parameters by which the doctor was to be notified. The prior order, dated 08/01/11, specified to notify the doctor if the fingersticks were below 60 ml/dl or over 200 ml/dl. Further record review disclosed that, on 09/05/11 at 6:00 a.m., the result of the resident's fingerstick blood sugar was 314 mg/dl. There was no evidence to reflect staff notified the physician of this elevated result, as specified in his order. During an interview with the administrator on 09/07/11 at 3:00 p.m., she reported that she questioned the nurses about this, and she verified that staff did not notify the doctor of this elevated blood sugar as specified in the physician's orders [REDACTED]. .",2014-11-01
10929,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,425,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that medications were available to meet the needs of the residents. Resident #68 did not receive insulin to treat her diabetes due to this medication not being available in the facility when it was time for her to have it. This practice affected one (1) of seventeen (17) sampled residents. Resident identifier: #68. Facility census: 98. Findings include: a) Resident #68 According to the nursing notes, this resident was admitted on [DATE] and arrived at the facility at 11:15 p.m. Her [DIAGNOSES REDACTED]. It was noted (on 09/06/11) that this medication was not recorded on the medication administration record until 09/06/11 at 1630 (4:30 p.m.). The hospital records indicated that, prior to this resident being discharged , she received her insulin at 5:00 p.m. on 09/05/11. There was no evidence the resident received the morning dose of 20 units of Novolin 70/30 Insulin as ordered at 0630 (6:30 a.m.) on 09/06/11. The resident's fingerstick at 1130 (11:30 a.m.) on 09/06/11 was 215 mg/dl. This was then repeated at 4:30 p.m., and her fingerstick blood sugar was 132 mg/dl. She then received her Novolin 70/30 insulin as ordered at 4:30 p.m. During an interview with the administrator on 09/07/11 at 3:15 p.m., she was questioned about this medication. She called the nurse at home at that time and verified that this medication was not administered that morning at 6:30 a.m. on 09/06/11, because it had not arrived from the pharmacy. The director of nursing, when interviewed on 09/08/11 at 11:00 a.m., was about the facility's procedure for obtaining medications when a resident is admitted late at night . She provided a copy of the facility's procedure for obtaining medications after hours. She verified the nurse should have called the on-call pharmacist's pager number.",2014-11-01
10930,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2009-07-31,364,F,0,1,U4H311,"Based on observation, menu review, taste testing, and staff interview, the facility failed to assure meals were attractive and flavorful. Residents' foods were not varied in color, creating an unattractive presentation. In addition, the macaroni and cheese, as prepared, had no flavor. These practices had the potential to affect all residents who received nourishment from the dietary department. Facility census: 57. Findings include: a) Observations during the noon meal, at 11:45 a.m. on 07/28/09, revealed the following: 1. The foods were all pale yellow to light orange in color, even the garnish. The residents' plates contained fish nuggets and macaroni and cheese. The garnish, selected by dietary personnel, was a peach slice. The dessert was a pudding parfait. It had chocolate on the bottom, but the visible portion was the vanilla on top with a dollop of white whipped topping. 2. Residents requiring pureed diets did not have the benefit of a garnish. The menu did not include a garnish for pureed meals. 3. Taste testing of the macaroni and cheese revealed it had no flavor. The dietary manager (DM), when asked to taste the product, confirmed it was not a flavorful product. Further investigation revealed the method of preparation had changed. A new powdered cheese sauce was used. It had not been added in sufficient quantity to give the macaroni and cheese a cheesy flavor. Interview with the DM, at that time, revealed there had been no determination for the amount of the new cheese sauce, to assure the macaroni and cheese was flavorful. .",2014-11-01
10931,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2009-07-31,441,D,0,1,U4H311,"Based on observation, the facility failed to ensure all staff members provided ice to residents in a manner to prevent the development and transmission of disease and infection. This practice affected one (1) resident but had the potential to affect other residents on A Hall. Facility census: 57. Findings include: a) On 07/30/09 at 3:55 p.m., a nursing assistant (Employee #12) was observed holding a pitcher over the ice chest when adding ice. This pitcher had been in a resident's room. This practice created a potential for contamination of the ice in the ice chest. Employee #52, another nursing assistant, intervened so no other resident was affected. When this was brought to the attention of supervisory nursing personnel, the ice chest was emptied and cleaned.",2014-11-01
10932,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2009-07-31,371,F,0,1,U4H311,"Based on observation, food temperature measurement, and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 57. Findings include: a) During observations of the dietary department, at 11:45 a.m. on 07/28/09, the following sanitation infractions were found: 1. The front of the exhaust vents, in the exhaust hood, contained greasy, dusty debris. At the time of the observation, the dietary manager (DM) was asked when they had last been cleaned. The DM replied she was uncertain, as maintenance was responsible for the cleaning of the vents. 2. The top of the Rubbermaid food cart was dusty. 3. Pureed macaroni and cheeses was not reheated prior to being placed on the steam table, after mechanical alteration with cold milk. Just prior to food service, the temperature of the product was 120 degrees Fahrenheit. .",2014-11-01
10933,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2009-07-31,309,D,0,1,U4H311,"Based on observations, resident interview, and review of medical records, the facility failed to ensure a resident was provided with necessary care and services to maintain her highest practicable physical well-being, in accordance with her comprehensive assessment and plan of care. A resident was observed sitting in a wheelchair with her leg extended. There was no support for her leg. Additionally, the resident was to wear a brace on her left ankle, but the brace was not applied as ordered for three (3) days of the survey. One (1) of thirteen (13) residents on the current sample was affected. Resident identifier: #16. Facility census: 57. Findings include: a) Resident #16 On 07/28/09 at 11:50 a.m., this resident was observed sitting in a wheelchair in the dining room. She was sitting upright with her left leg extended unsupported. When asked about her leg, she said she had broken her hip over a year ago and it did not bend much. When asked whether she was comfortable, she said her leg gets tired and her ankle hurt like a toothache; she also said she had just told the nurse about this. The resident commented that, when she relaxed her leg, her ankle did not hurt so much - it still hurt, but a lot less. She also said staff did not put anything behind her leg / foot and added, ""I need it propped up on something - it might help - I'm not sure."" Review of the resident's medical record found her physician had ordered a brace applied to her left foot and ankle. It was to be applied in the morning and removed at bedtime. Observations, on 07/28/09, 07/29/09, and 07/30/09, found the resident did not have the brace on, nor was there a foot / leg rest on her wheelchair. On the morning of 07/31/09, the resident was observed to have a foot / leg rest on her wheelchair. Her leg brace had also been applied. According to the resident, her leg felt better. .",2014-11-01
10934,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2009-07-31,315,D,0,1,U4H311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to identify, develop, and implement a plan to attempt to ensure a resident received appropriate treatment and services to restore as much normal bladder function as possible. A voiding diary was completed for a three (3) day period, which provided an indication the resident had some control over her bladder. However, there was no evidence the diary was analyzed to determine whether there was a pattern to the resident's voiding and whether she was a candidate for any type of urinary continence program. Resident identifier: #30. Facility census: 57. Findings include: a) Resident #30 Review of the resident's medical record found the resident had been admitted to the facility on [DATE]. The resident's admission minimum data set (MDS) assessment, with an assessment reference date of 07/07/09, reflected the resident was totally incontinent of urine for the fourteen (14) day look-back period. The assessment also reflected the resident required extensive assistance for transfers and was totally dependent for toilet use. Her short and long-term memories were assessed as being okay. It was also noted the assessment indicated the resident had not consumed sufficient fluids for the last three (3) days (which should have been for 07/05/09, 07/06/09, and 07/07/09). The resident assessment protocol (RAP) for urinary incontinence referred to the activities of daily living (ADL) RAP. The ADL RAP noted she was incontinent of bowel and bladder and was not a candidate for bowel and bladder retraining at that time, because of her condition. In another section, it was noted the resident required the assistance of two (2) staff members and a lift to transfer. The RAP did not specify what about ""her condition"" prevented her from participating in a retraining program and did not indicate whether she might benefit from another type of continence management program. The admission nursing assessment, dated 06/26/09, was checked to indicate the resident used the toilet, a bedpan, or a bedside commode. ""Yes"" was checked for ""Continent"". In the section titled ""Narrative Note"", the nurse had written, ""A & O (alert and oriented) x 3. Cont(inent) of B&B (bowel and bladder)."" At 2:40 p.m. on 07/30/09, Employee #78 provided a copy of the resident's ""24 Hour Voiding Diary"". She said she was unable to find an assessment based on the information recorded on the voiding diary. Review of the voiding diary found it had been completed every two (2) hours for twenty-four (24) hours on 07/01/09 and 07/02/09. Only eight (8) of the twelve (12) 2-hour periods were completed for 07/03/09. On 07/01/09 and 07/02/09, the section for ""Aware of Urge to Void"" was marked ""N/A"" (not applicable) in both the ""Yes"" and ""No"" columns, except for one (1) time ""Yes"" was noted at 1200 hours and ""No"" was noted at 1400 hours, on 07/02/09. Nothing was marked in the column on 07/03/09. Further review of the voiding diary found it indicated she had only had two (2) episodes of urinary incontinence (both were of small amounts) for a 24-hour period on 07/01/09. This indicated the resident was not excreting sufficient amounts of urine. The resident's fluid intake was also documented on this form. The total of the fluid intake documented was 480 cc. There was no evidence the resident's low urinary output had been identified. Additionally, the resident was noted to be dry on the other ten (10) two 2-hour periods, which would indicate she had some control of her bladder. On 07/02/09, the diary indicated the resident voided a small amount twice and a medium amount twice. She was noted to be dry the other eight (8) 2-hour periods. Again, this indicated the resident had some control over her bladder and suggested the resident needed to consume more fluids. There was no evidence the voiding diary had been reviewed and an assessment made with consideration given to her insufficient output, apparent insufficient intake, and the fact that she was often dry, indicating a degree of bladder control. The was no evidence it had been ascertained why staff had marked ""N/A"" in both the ""Yes"" and ""No"" columns for ""Aware of Urge to Void."" Additionally, under a heading of ""Voided"", there were two (2) columns - one (1) for ""Bedpan"" and another for ""Toilet / Commode"". Both columns were marked ""N/A"". There was no indication the resident had been placed on a bedpan or other urine collection device to see if she could void. Although the resident required the assistance of two (2) staff members and use of a lift to transfer, this would not preclude attempts to maintain continence using a bedpan, a bedside commode, or by placing her on the toilet. .",2014-11-01
10935,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2011-07-19,202,D,1,0,UZ6R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to provide the medical power of attorney representative (MPOA) and/or interested family members with a reason for discharge and/or alternatives to discharge, including appeal rights, for one (1) of nine (9) sampled residents. Resident identifier: #70. Facility census: 67. Findings include: a) Resident #70 A review of the closed medical record of Resident #70 revealed this [AGE] year old female had been determined by her physician, on 04/03/11, to lack the cognitive ability to make healthcare decisions. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's note dated 03/31/11 stated she was ""... alert / oriented and agreeable with POC (plan of care)."" A review of her care plan, dated 04/22/11, revealed she ""... exhibited some behaviors during my review period such as yelling, and becoming tearful"" and that she had difficulty understanding and processing information. Nursing interventions were planned which remained unchanged throughout her admission. Documentation on her pre-admission screening (form PAS-2000) indicated her nursing home stay was planned for less that three (3) months, and the discharge plan indicated, on 04/22/11, that her stay was ""short-term"" and she was to return home with home health care. She was receiving no psychoactive medications at the time of admission. In May 2011, the resident had a psychiatric consult and was started on [MEDICATION NAME] and [MEDICATION NAME] because of ""generalized anxiety disorder AEB (as exhibited by) increased agitation and crying episodes"". The nurses notes in June 2011 intermittently recorded increased behavioral episodes which included combativeness, resisting care, and cursing at staff. This was reported to the physician, who ordered [MEDICATION NAME] on 06/16/11. This medication was started at 9:00 a.m. on 06/20/11. The resident's care plan was revised on 06/21/11 to include: ""... at risk for leaving the building unassisted. I am confused and agitated at times."" However, the care plan did not identify any concerns related to physically and/or verbally abusive behaviors. The record revealed the social worker (Employee #4) met with the resident's MPOA on 06/17/11, discussed ""behaviors occurring daily"" with the resident, and suggested that they may need to consider moving her to a facility better equipped to care for persons with her problems. This was confirmed during an interview with the social worker at 11:10 a.m. on 07/19/11, who stated this was her last conversation with the son, because she was not on duty when the resident was transferred out of the facility on 06/21/11. The resident was transferred to an acute care hospital at 5:00 p.m. on 06/21/11, after a behavioral episode which included throwing objects across her room. The nurse's entry at that time stated: ""(Resident #70) transferred to hospital - unplanned for evaluation and treatment via ambulance to (hospital). Physician notified of transfer. ... Copy of advance directives sent. See transfer form for additional clinical findings."" The only clinical finding documented on the transfer form was ""behaviors"", which was entered as the [DIAGNOSES REDACTED]. A nurse's note, which was recorded as a late entry at 2:17 p.m. on 06/22/11 by the registered nurse (RN) manager (Employee #3), stated: ""Client had several episodes of behaviors outbursts. Client found in room with possessions on bedside table, and table it self, thrown across room. When staff nurse asked client what had occurred and who had thrown objects, Client stated, 'the cat did it, I was sitting on the couch.' Client's MPOA called by staff nurse with fell ow staff nurse present. Asked MPOA to come in and try to calm down client. MPOA stated he'd be there in one hour. Client's daughter arrived shortly after. Staff nurse and administrator discussed recent outbursts of behavior and other options that might be more beneficial to client. Staff nurse mentioned family might be interested in having her evaluated by a hospital that has a unit more specialized to her needs, ex. (hospital name). Daughter discussed with son, MPOA. Both agreed that would be a good option for client to receive further evaluation and treatment. Staff nurse call to set up transport... Staff nurse stated several times to family that this would be private pay transportation. MPOA stated that he understood and that would not be a problem. Staff nurse's also reeducated that although client was going for evaluation and treatment to hospital, does not mean that she would be admitted . MPOA stated he understood. Client with family for remainder of afternoon and dinner until transportation arrived. Report called to receiving facility."" During an interview with Employee #3 at 12:50 p.m. on 07/19/11, she confirmed she made the above entry and stated the resident had begun to calm down and became calm when the family arrived. Employee #3 stated she told them they should consider a facility better equipped to handle the behaviors and they agreed. During an interview with the resident's daughter at 11:40 a.m. on 09/19/11, she stated that, on the day of the transfer, she arrived at the hospital shortly before her brother and they spoke to the nurse who stated she was the supervisor in charge. They were told that the facility ""couldn't handle her anymore"" and they were given two (2) hospital options. She and her brother talked and chose which hospital and an ambulance was called. She stated she called back to the facility the next day and talked to the administrator, telling her the resident had been admitted to the hospital with [REDACTED]. The daughter stated, ""The administrator did not comment other than expressing surprise."" She stated that no one mentioned to either of them about readmission to this facility and her understanding was that they could not bring her back. She added that, after being treated for [REDACTED]. During an interview with the administrator at 8:30 a.m. on 07/19/11, she stated there were problems with the resident throughout her stay at the facility, which included physical aggression that escalated prior to discharge. She stated it was her understanding that the MPOA placed the resident in a behavioral treatment facility when she was released from the hospital. The administrator also stated she thought there was a payment problem because her Medicare had been depleted, but she acknowledged she was not sure of the source of this information and that she had not discussed this with the family, although she thought the social worker was attempting alternative placement. A review of the medical record revealed a Notice of Transfer or Discharge form containing the resident's last name and medical record number written in at the bottom, but the rest of the form was blank. This was presented to the administrator (Employee #1) at 10:54 a.m. on 07/19/11 with a request for any evidence that the family had been informed of the final disposition of the resident at the time of transfer and/or discharge. During an interview with the administrator and the social worker at 11:10 a.m. on 07/19/11, they acknowledged there was no additional documentation and both stated they had not spoken to the family since the resident was transferred. The social worker stated she had recently mailed a form to the MPOA containing the Right to Appeal process, but she had no proof of this and had received no response. The social worker again stated the aforementioned conversation with the MPOA was the extent of her involvement. In a follow-up interview with the administrator at 1:10 p.m. on 07/19/11, after the interview with the daughter of the resident, the administrator again stated she had not spoken with the family after the transfer and further stated she had not refused to readmit the resident after hospitalization . At the time of exit at 2:30 p.m. on 07/19/11, this surveyor had received no information stating the reason for discharge or any discharge planning information indicating that alternative placement had been requested or was being sought by the facility.",2014-11-01
10936,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2011-07-19,280,D,1,0,UZ6R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review / revise the care plan of one (1) of nine (9) sampled residents, when she began to exhibit verbally and physically abusive behaviors towards others that affected her discharge plan. Resident identifier: #70. Facility census: 67. Findings include: a) Resident #70 A review of the closed medical record of Resident #70 revealed this [AGE] year old female had been determined by her physician, on 04/03/11, to lack the cognitive ability to make healthcare decisions. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's note dated 03/31/11 stated she was ""... alert / oriented and agreeable with POC (plan of care)."" A review of her care plan, dated 04/22/11, revealed she ""... exhibited some behaviors during my review period such as yelling, and becoming tearful"" and that she had difficulty understanding and processing information. Nursing interventions were planned which remained unchanged throughout her admission. Documentation on her pre-admission screening (form PAS-2000) indicated her nursing home stay was planned for less that three (3) months, and the discharge plan indicated, on 04/22/11, that her stay was ""short-term"" and she was to return home with home health care. She was receiving no psychoactive medications at the time of admission. In May 2011, the resident had a psychiatric consult and was started on [MEDICATION NAME] and [MEDICATION NAME] because of ""generalized anxiety disorder AEB (as exhibited by) increased agitation and crying episodes"". The nurses notes in June 2011 intermittently recorded increased behavioral episodes which included combativeness, resisting care, and cursing at staff. This was reported to the physician, who ordered [MEDICATION NAME] on 06/16/11. This medication was started at 9:00 a.m. on 06/20/11. The resident's care plan was revised on 06/21/11 to include: ""... at risk for leaving the building unassisted. I am confused and agitated at times."" However, the care plan did not identify any concerns related to physically and/or verbally abusive behaviors, nor was there any indication that her stay would be other than short-term. The record revealed the social worker (Employee #4) met with the resident's MPOA on 06/17/11, discussed ""behaviors occurring daily"" with the resident, and suggested that they may need to consider moving her to a facility better equipped to care for persons with her problems. This was confirmed during an interview with the social worker at 11:10 a.m. on 07/19/11, who stated this was her last conversation with the son, because she was not on duty when the resident was transferred out of the facility on 06/21/11. The resident was transferred to an acute care hospital at 5:00 p.m. on 06/21/11, after a behavioral episode which included throwing objects across her room. The nurse's entry at that time stated: ""(Resident #70) transferred to hospital - unplanned for evaluation and treatment via ambulance to (hospital). ..."" During an interview with the administrator (Employee #1) at 8:30 a.m. on 07/19/11, she stated there were problems with the resident throughout her stay at the facility, which included physical aggression that escalated prior to discharge. When informed at that time of the lack of care planning for any physical or verbal aggression or changes in discharge planning, the administrator stated she would investigate this. During an interview with the administrator and the social worker at 11:10 a.m. on 07/19/11, they acknowledged there was no evidence of changes in made to the resident's discharge plan, and the administrator agreed the care plan was not revised to address the problems of physical and/or verbal aggression.",2014-11-01
10937,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,272,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure the accuracy of information recorded on the minimum data set assessment (MDS) for three (3) of thirteen (13) sampled residents. Resident identifiers: #38, #2, and #4. Facility census: 61. Findings include: a) Resident #38 Review of the resident's abbreviated quarterly MDS, dated [DATE], revealed, in Section M.1., that Resident #38 had one (1) Stage II pressure ulcer. Review of the nursing notes and body assessments for the two (2) weeks preceding 04/04/09 failed to find any evidence of a pressure sore. This was verified by the wound care nurse (Employee #46) during an interview at 10:00 a.m. on 06/16/09. During an interview with the MDS nurse at 10:45 a.m. on 06/16/09, she reviewed the record, acknowledged an entry error had been made, and stated she would correct it immediately. b) Resident #2 Review of the clinical record revealed Resident #2 had a physician's orders [REDACTED]. The director of nursing (DON) verified the resident could not remove the seat belt at will and acknowledged this device served as a physical restraint to promote safety. The resident was observed with the belt in place at 10:50 a.m. on 06/16/09. A review of the resident's abbreviated quarterly MDS, dated [DATE], revealed, in Section P.4., the resident did not have a physical restraint is use. When informed of this, the DON acknowledged this was an error and stated the MDS would be corrected to include restraint use. c) Resident #4 Record review, on 06/16/09, revealed an admission MDS completed on 01/23/09, in which the assessor indicated the resident had ""pain less than daily"". An abbreviated quarterly MDS, completed on 04/07/09, indicated the resident had ""no pain"". Review of the resident's clinical record, for the seven (7) day look-back time frame prior to the 04/07/09 quarterly MDS, revealed the resident did have pain; however, it was not daily. Interview in the morning on 06/18/09, Employee #56 stated she reviewed the resident's medication administration records, nursing notes, and activities of daily living flow sheet for evidence of reports of pain. This employee acknowledged there was an error on the quarterly MDS and stated it should have indicated pain less than daily. .",2014-11-01
10938,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,371,F,0,1,HO2T11,"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. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 61. Finding include: a) At 6:30 a.m. on 06/15/09, observations in the dietary department with the dietary manager (DM) revealed the steam table nesting pans were stacked inside of each other prior to air drying. These items were observed with trapped moisture, creating a medium for bacteria growth. b) Observations in the dry food storage area revealed a tray of empty cereal bowls that were stored right side up with the bowls not covered. The dietary manager stated the bowls had been placed in this area the night before. Observation of the five-gallon plastic container used for sugar storage revealed the cover was not put on securely; the sugar was not covered completely and prevented the food item from being stored in an air tight container. These two (2) food storage practices have the potential for not maintaining sanitary conditions that promote safe food handling. c) The DM confirmed the observations as seen by the surveyor. .",2014-11-01
10939,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,514,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain an accurate clinical record with respect to the resuscitation status of one (1) of fifteen (15) sampled residents. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 Review, on 06/16/09, of the resident's current monthly recapitulation of physician orders [REDACTED]. Review of Section A of the Physician order [REDACTED]. This POST form was initially signed by the physician on 01/05/05. Review of the resident's annual history and physical, signed by the physician on 01/12/09, revealed: ""CODE STATUS: Full Resuscitation"". In an interview at 9:00 a.m. on 06/17/09, the director of nursing acknowledged the ""full code"" noted on the history and physical was an error, and the resident was currently receiving Hospice care. She confirmed the POST form and the June 2009 physician orders [REDACTED].",2014-11-01
10940,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,274,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to recognize and complete a comprehensive assessment after a significant change in the resident's health status for one (1) of thirteen (13) sampled residents. Resident identifier: #38. Facility census: 61. Findings include: a) Resident #38 A review of Resident #38's clinical record revealed several changes in the minimum data set assessment (MDS) for the period ending 04/04/09 from the previous one completed on 01/29/09. The changes are as follows: - In Section B.5.f. - The resident's mental status varies over the course of the day. (She did not previously exhibit this.) - In Sections E.1.d. & l.) - The resident exhibits persistent anger with self or others and sad, pained, worried facial expressions up to five (5) days a week. (She did not previously exhibit this.) - In five (5) areas of activities of daily living (ADL) self-performance the resident declined from limited (2) to extensive (3) assistance required for performance. These were bed mobility, transfer, walking in the room, dressing, and toilet use. Because a comprehensive assessment was not completed, no resident assessment protocols (RAPs) were triggered for completion to address [MEDICAL CONDITION], mood, or ADL function. During an interview with the MDS nurse at 10:45 a.m. on 06/16/09, she acknowledged the differences were accurate but stated the computer had not alerted her to the need to complete a significant change in status assessment and, therefore, one was not done. .",2014-11-01
10941,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,329,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a gradual dose reduction (GDR) [MEDICATION NAME] attempted (to determine if symptoms could be managed by a lower dose or if the medication could be discontinued) and/or failed to ensure the physician recorded a clinical rationale for not attempting the GDR, for one (1) of thirteen (13) sampled residents. Resident identifier: #15. Facility census: 61. Findings include: a) Resident #15 A review of Resident #15's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had been receiving ""Ambien 5 mg tablets daily at bedtime"" since 10/29/08, for sleeplessness without an attempt at GDR. Review of the nursing notes failed to find any mention of the resident having problems sleeping during this time. Her behavior monitoring sheets also recorded no instances of sleeplessness. During the medication regimen review, the consultant pharmacist suggested a GDR be attempted on 01/29/09 and again on 02/20/09. Although the physician rewrote all the medication orders on 02/09/09, no changes were made in [MEDICATION NAME]. The director of nursing (DON) also made a recommendation, on 02/01/09, that the physician ""consider identifying resident-specific non-pharmacologic interventions"". He did not. There was no documented evidence in the physician's orders [REDACTED].#15. During an interview with the DON and the assessment nurse at 11:30 a.m. on 06/16/09, the DON reviewed the record and was unable to produce any additional documentation regarding why a GDR had not been attempted. Although she stated the resident requested [MEDICATION NAME] continued, she was also unable to show documentation of this. .",2014-11-01
10942,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,159,B,0,1,HO2T11,"Based on record review and staff interview, the facility failed to obtain written authorization from the legal representatives, of five (5) of six (6) sampled residents with lack capacity, prior to holding and managing personal funds for these residents. Resident identifiers: #15, #23, #26, #39, and #41. Facility census: 61. Findings include: a) Resident #15 Medical record review revealed Resident #15 lacked capacity, and a representative from West Virginia Department of Health and Human Resources (DHHR) had been appointed as health care surrogate (HCS) to make medical decisions, because both the resident's daughter and her sister declined this responsibility. Resident #15 had $1,860.39 in a personal funds account being held and managed by the facility based on the signature of her daughter, although there was no evidence the daughter had the legally authority to either grant this permission or determine how the money would be disbursed. During an interview with the social worker at 4:00 p.m. on 06/16/09, she stated the resident's daughter had told her she was the resident's power of attorney (POA), but the daughter had never produced the documentation to verify this claim. b) Resident #23 Medical record review revealed Resident #23 lacked capacity to make medical decision, and a HCS was appointed to make these decisions for him. Resident #23 had $1700.63 in a personal funds account being held and managed by the facility based on the signature of the HCS, although there was no evidence the HCS had the legally authority to either grant this permission or determine how the money would be disbursed. (State law does not authorize a HCS to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, who was responsible for managing the personal funds accounts, she stated she was aware of this and that part of this money was to be paid to the funeral home for a burial plan. c) Residents #26 and #39 Residents #26 and #39, both of whom had been determined to lack capacity, had designated medical power of attorney representatives (MPOAs) to make their medical decisions for them. In both cases, the MPOAs for Residents #26 and #39 gave signed authorization for the facility to manage the residents' personal funds accounts. However, a review of the documentation failed to produce any evidence of the MPOAs had the legal authority to make financial decisions on behalf of these residents. (State law does not authorize a MPOA to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, she stated she was aware that neither resident had designated a power of attorney to make financial decisions on their behalf.. d) Resident #41 Resident #41 had been adjudged incompetent and had a legal guardian appointed by the court to make medical decisions. This guardian gave signature authorization for the facility to manage the resident's personal funds. Review of the legal documents found no evidence that this guardian had also been appointed to serve as conservator, which would have given the guardian legal authority to make financial decisions for the resident. During an interview with Employee #62, she stated she was aware that Resident #41's legal representative was limited to guardianship only. .",2014-11-01
10943,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,152,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ascertain a capacitated resident's wishes with respect to advance directives, allowed a medical power of attorney representative (MPOA) to make a health care decision on behalf of the resident without the legal authority to do so, and failed to identify and resolve conflicts between physician's orders [REDACTED]. Resident identifier: #4. Facility census: 61. Finding include: a) Resident #4 Review of Resident #4's medical record, on 06/17/09, revealed she was admitted to the facility on [DATE], with admitting orders signed by the physician for ""Advance Directives: DNR (do not resuscitate)."" Review of the ""Physician Determination of Capacity"", dated 01/11/09, revealed the resident had the capacity to understand and make her own informed health care decisions. The ""staff member involved"" with the completion of Resident #4's Advanced Directive Acknowledgment Form (Employee #63) marked an ""X"" at Item 6 indicating, ""Do not perform cardiopulmonary resuscitation"", and recorded, ""Per conservation with POA (power of attorney) 01/09/09 2:50 PM."" There was no signature of the form from the person making this health care decision on behalf of Resident #4, and there was no indication that Resident #4, who had the capacity to make this decision herself, was consulted regarding this matter. The ""physician acknowledgement"" of the form was signed by the physician on 01/09/09. Review of the resident's history and physical, dated and signed by the physician on 01/12/09 at 3:50 p.m., revealed: ""CODE STATUS: FULL RESUSCITATION in the event of cardiopulmonary arrest, including intubation with mechanical ventilation and/or cardioversion pending her POST form and official DNR status. Will get further details from the long-term care unit."" Review of the Physician order [REDACTED]. The form had been signed by the resident's MPOA - not the resident, and the MPOA's signature was not dated. The physician had signed and dated the form on 01/18/09. Interview with the director of nursing (DON), on the afternoon of 06/17/09, confirmed there was conflicting information regarding the resident's advances directives. The DON said the facility would need to ascertain the resident's desires with respect to resuscitation status and honor her wishes. .",2014-11-01
10944,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,154,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy regarding cardiopulmonary resuscitation (CPR), and staff interview, the facility failed to ensure residents were fully informed in advance of care or treatment that might affect their well-being. Resident #94's medical record included a Physician order [REDACTED]. There was no evidence the resident / responsible party had been made aware of the facility's policy. One (1) of eight (8) residents whose closed record was reviewed was affected. Resident identifier: #94. Facility census: 86. Findings include: a) Resident #94 Review of the resident's medical record found a POST form had been completed by the resident's medical power of attorney representative (MPOA) on [DATE]. The MPOA had checked the POST form, indicating the resident was to be resuscitated. Further review of the medical record found an entry, dated [DATE] at 3:00 a.m., recording, ""Called to residents (sic) room by staff at 12:30 AM (sic) No pulse - radial/carotid. No respirations. Skin cold to touch. Pupils fixed / dilated /c (with) pupil indented. Tem (temperature) 87.2 (degree mark) F...."" The note continued, and the MPOA was quoted as saying, ""I spent a long time with her a couple of days ago and I have been expecting this."" No attempts were made to provide CPR. The director of nursing (DON), when interviewed regarding these findings at 7:45 a.m. on [DATE], stated they have night time briefs so staff do not have to disturb residents so often. She said staff does not go in and check to see whether residents are still breathing every two (2) hours, as this would disturb the sleeping residents. The DON said this resident had been stiff when she was found, and the resident's death was ""very unexpected"". The DON was asked whether there was a policy regarding when CPR would be provided. Shortly after, she provided a copy of the facility's policy entitled ""Cardiopulmonary Resuscitation."" The policy included, ""Cardiopulmonary resuscitation (CPR) will be instituted in cases of witnessed cessation of cardiac and/or [MEDICAL CONDITION] function until advanced cardiac life support is available on any resident who does not have a 'Do Not Resuscitate' order."" (The policy did not have a date, so it could not be ascertained whether it had been in place in 2005.) When asked whether residents or their responsible parties were informed of this when they completed the POST form, the DON said the social workers explain this when the POST form is signed. Approximately one (1) hour later, Employee #51 (a facility social worker) was asked about what she told people when they were deciding how to fill out the POST form. She provided a thorough explanation but did not mention the facility's CPR policy. When specifically asked about this policy, she said she was not aware of it. She added that, fortunately, she had not had admitted anyone who had wanted CPR. It was suggested she obtain a copy of the policy. .",2014-11-01
10945,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,156,C,0,1,T34S11,"Based on observation and staff interview, the facility failed to post accurate information regarding the regional ombudsman. This practice had the potential to affect all residents. Facility census: 86. Findings include: a) During the initial tour of the facility on 05/18/09 at approximately 3:45 p.m., observation revealed the signs posted in the front lobby area of the building contained the incorrect telephone number and no name listed for the regional ombudsman. Other signs containing this same type of information were posted in various locations throughout the building and did have to correct information related to the regional ombudsman. At approximately 5:00 p.m. on 05/18/09, the administrator agreed the sign in the front area of the building needed to be corrected. .",2014-11-01
10946,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,157,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to notify the physician when a resident repeatedly refused a medication in the evenings. The resident's medication administration records (MARs) indicated she had refused an evening dose of [MEDICATION NAME] for at least the last four (4) months. There was no evidence the physician had been notified of the resident's continued refusal to take the medication. Resident identifier: #51. Facility census: 86. Findings include: a) Resident #51 A nurse (Employee #7) was observed administering medications to this resident at approximately 7:10 p.m. on 05/20/09. She poured the resident's dose of [MEDICATION NAME], then initialed and circled the space for the resident's evening dose of [MEDICATION NAME] (ordered for constipation). As she did so, she explained the resident had been refusing to take the medication. On 05/22/09, the resident's MARs for February, March, April, and May 2009 were reviewed. The medication had consistently been circled, and an ""R"" had been written under the nurses' initials to indicate she had refused the medication. There was no evidence the physician had been notified so that he/she would be aware and might determine whether the resident's medication regimen needed to be changed. .",2014-11-01
10947,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,240,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility did not ensure staff provided residents with care and services in a manner and in an environment that promoted comfort and/or enhanced quality of life, affecting three (3) of fifteen (15) sampled residents. Resident #57 did not have access to her bedside table which contained a glass of water. Resident #74's call light was not placed within her reach to allow her to summon staff assistance when needed. Resident #44 complained of being cold. She told the nurse she had asked staff for a blanket three (3) times but had not yet received one. The nurse assured her one would be provided for her, but the nurse forgot to do so after she administered the resident's medications. Resident identifiers: #57, #74, and #44. Facility census: 86. Findings include: a) Resident #57 On 05/20/09 at approximately 8:20 a.m., Resident #57 asked for something to drink. Her bedside table was pushed up against the wall out of her reach. The resident had fall mats beside her bed, making it difficult to place the bedside table within her reach. Employee #17 (a licensed practical nurse) indicated the resident could not get her own water without pouring it out onto her clothing. On 05/20/09 at approximately 1:05 p.m., the director of nursing indicated the resident probably could drink from her glass but could not pour water out of her pitcher. The DON said the fall mats should not prevent the resident's table from being within her reach. She also felt it was important for the resident to have access to fluids, even though she does get fluids during the scheduled hydration pass. The minimum data set (MDS) quarterly review, with an assessment reference date (ARD) of 04/12/09, indicated the resident needed set up help only with eating. The resident also had a care plan in place for dehydration. b) Resident #74 On 05/19/09 at approximately 1:00 p.m., residents were eating lunch in their rooms. Resident #74 asked to go to the bathroom. She was sitting in a geri chair with her meal tray in front of her. She did not have a call light within her reach. The call light, which was hanging from the wall, was not accessible to the resident. The resident also could not ambulate due to a recent [MEDICAL CONDITION] (stroke). At approximately 1:05 p.m., a staff member (Employee #10) was asked to come and assist the resident. Staff interviews verified the resident could utilize her call light if it was within her reach. c) Resident #44 When the nurse (Employee #11) went into the resident's room to administer her morning medications at approximated 8:30 a.m. on 05/19/09, the resident stated, ""I'm freezing!"" The nurse asked the resident whether she wanted another blanket. The resident replied she did, and said, ""I've asked three (3) people this morning"" and had not gotten one. After the nurse administered the resident's oral medications and eye drops, she washed her hands and started to take the cart down the hall toward the nurses' station. When reminded about her promise to get the resident a blanket, she said she had forgotten and went to get a blanket. The resident expressed her appreciation. At 10:00 a.m., the resident was asked whether she was still cold. She said the blanket the nurse had put on her a little while before made her warm enough. At approximately 2:00 p.m. on 05/22/09, the resident again said she had asked three (3) staff members for a blanket that morning but did not receive one until the nurse got one for her after she had taken her medications. .",2014-11-01
10948,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,279,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review and staff interview, the facility failed to ensure all interventions being used to prevent one (1) of fifteen (15) residents from having skin breakdown were included in the section of the care plan pertaining to this issue. Resident identifier: #53. Facility census: 86. Findings include: a) Resident #53 A review of Resident #53's care plan revealed the following problem statement: ""Potential altered skin integrity R/T (related to): urinary / bowel incontinence."" The resident had a physician's orders [REDACTED]. This intervention was not listed on the care plan. The director of nursing agreed this intervention needed included in the care plan. .",2014-11-01
10949,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,281,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, staff interview, and review of the facility's policy regarding medications, the facility failed to ensure staff followed facility policy and generally accepted guidelines when a resident repeatedly refused a medication in the evenings. The resident's medication administration records (MARs) indicated she had refused an evening dose of [MEDICATION NAME] for at least the last four (4) months. There was no evidence the physician had been notified, nor was there documentation found to indicate nurses had explored why the resident did not take the medication. Resident identifier: #51. Facility census: 86. Findings include: a) Resident #51 The nurse (Employee #7), when administering medications to this resident at approximately 7:10 p.m. on 05/20/09, initialed and circled the space for the resident's evening dose of [MEDICATION NAME], saying the resident had been refusing to take the medication. She did not check with the resident first, nor did she make a notation regarding why the medication was not given other than to put an ""R"" to indicate it had been refused. On 05/22/09, the resident's MAR for February, March, April, and May 2009 were reviewed. The medication had consistently been circled, and an ""R"" had been written under the nurses' initials to indicate she had refused the medication. Review of the backs of the MARs and the nursing entries for these months found nothing to indicate why the resident had refused the medication. On 05/22/09 at 9:55 a.m., the resident was asked why she refused the medication in the evening. She replied she received the medication twice a day and did not feel she needed it twice a day every day. Review of the facility's policy entitled ""Preparation and General Guidelines"" found, ""If a dose of regularly scheduled medication is withheld, refused, or given other than the scheduled time... the space of the front of the MAR for that dosage administration is (initialed and circled). An explanatory note is entered on the reverse side of the record provided for PRN (as needed) medication. ..."" .",2014-11-01
10950,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,309,E,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, staff interviews, and resident interviews, the facility failed to ensure residents were assessed for efficacy of treatment changes; positioned to facilitate comfort and/or good body alignment; and received adaptive equipment as ordered by the physician. A resident had [MEDICAL CONDITION] for which the dosage of her diuretic was changed, but there was no evidence the effectiveness of this medication was monitored. Two (2) residents were observed while in bed without benefit of having been positioned for comfort, to enhance their physical abilities, and/or to maintain good body alignment. Two (2) residents had orders for specific devices for their wheelchairs which were no employed. Five (5) of fifteen (15) current residents on the sample were affected. Resident identifiers: #61, #44, #86, #47, and #53. Facility census: 86. Findings include: a) Resident #61 During the initial tour of the facility on 05/18/09 at approximately 4:15 p.m., observation found this resident sitting in her wheelchair in her room. Her feet were propped up on her bed, and her ankles and feet appeared [MEDICAL CONDITION]. After lunch on 05/20/09, the resident put her feet up on her bed while she was sitting in her wheelchair, She said, ""They don't even go down at night anymore."" She added that the [MEDICAL CONDITION] in her feet and legs used to go ""down"" at night while she was in bed. On 05/20/09 at 6:10 p.m., the resident was again observed. She again was sitting in her wheelchair with her feet propped up on her bed. Her feet, ankles, and lower legs were [MEDICAL CONDITION]. She said, ""They haven't told me what's wrong, but it's getting so they don't go down at night."" Review of the resident's medical record found the following: 1. She had been initially admitted to the facility on [DATE], with readmitted s of 02/12/09 and 03/19/09. 2. Her [DIAGNOSES REDACTED]. 3. A history and physical completed by the physician, dated 03/19/09, after her return from the hospital, noted she had been in the hospital for [MEDICAL CONDITION] bilaterally. Under ""Extremities"", the physician had circled ""[MEDICAL CONDITION]"" and noted ""Lt (left) leg"". The hospital discharge summary for this date noted she had bilateral lower leg [MEDICAL CONDITION]. ""Patient had a Doppler ultrasound done which revealed a [MEDICAL CONDITION] involving the right common femoral vein and the left common and superficial vein."" 4. A physician's progress note, dated 03/11/09, indicated the resident had 1+ [MEDICAL CONDITION]. ""[MEDICAL CONDITION]"" had been circled related to her extremities and written in beside decreased mobility on a progress note dated 03/04/09. ""Legs (+) (positive) [MEDICAL CONDITION]"" had been noted by the physician in a notation on 04/10/09. A progress note, dated 04/21/09, had a circle drawn around pedal [MEDICAL CONDITION] under the section for ""Cardiac"", another drawn around the word [MEDICAL CONDITION] under ""Extremities"", and ""Peripheral [MEDICAL CONDITION]"" had been noted under the diagnoses. It was also noted, ""Will increase [MEDICATION NAME] & monitor BMP (a lab test)."" On 05/06/09, the physician again circled pedal [MEDICAL CONDITIONS], and wrote [MEDICAL CONDITION]. The resident was noted to have dyspnea, and a chest x-ray was ordered. 5. Review of her physician's orders [REDACTED]. The [MEDICATION NAME] was increased to 40 mg daily on 04/21/09. On 05/06/09, the physician increased the dose of [MEDICATION NAME] to 60 mg daily and ordered a chest x-ray (as was noted in the corresponding physician's progress note of that date). On 05/11/09, the dose of [MEDICATION NAME] was changed to 40 mg twice a day. 6. Review of nursing entries on the ""Daily Skilled Nurses Notes"" found the forms had been checked for 1+ pitting pedal [MEDICAL CONDITION] of the left leg on all three (3) shifts on 04/30/09 through 05/04/09. On 05/05/09, day shift and evening shift also checked this. On 05/07/09 at 9:00 a.m., on the back of the form, a nurse noted, ""Received [MEDICATION NAME] 60 mgm this am left leg much more [MEDICAL CONDITION]. ..."" Nothing regarding [MEDICAL CONDITION] had been checked on the front of the form. There was no further documentation regarding the [MEDICAL CONDITION] until 05/12/09. ""[MEDICAL CONDITION] legs"" had been written in on the front of the ""Daily Skilled Nurses Notes"" form and checked by all three (3) shifts. As on 05/22/09, no further nursing entries regarding the resident's [MEDICAL CONDITION]. 7. The resident had been observed to have pedal and lower leg [MEDICAL CONDITION] on 05/18/09, 05/19/09, 05/20/09, and 05/21/09. There was no evidence in the resident's medical record to indicate the [MEDICAL CONDITION] was being monitored by staff so the effectiveness of treatment could be assessed. On 05/22/09 at 8:40 a.m., it was noted the [MEDICAL CONDITION] had diminished. When this was mentioned to the resident, she said she did not know why, but they had gone down. She said she had been up and down to the bathroom all night, and her feet and legs had finally gone down. -- b) Resident #44 During the observation of morning medication pass on 05/19/09, the resident was in bed, leaning to her right. Periodic observations, on 05/19/09, 05/20/09, and 05/21/09, found her in essentially the same position. On 05/22/09 at 9:00 a.m., the resident was again observed while in bed. The head of the bed was elevated approximately 30 degrees, and the resident was leaning to her right. This placed her head and shoulder near the edge of the bed and the side rail. It was noted the resident used her right arm, but this was limited because of her leaning to her right. She did not move her left hand / arm. On 05/22/09 at 9:05 a.m., Employee #11 was asked whether the resident was able to move her left arm at all and replied, ""No."" The resident was asked whether she would be more comfortable if her shoulders were moved to the left. She looked at a label on the side rail, that was inches from her eyes, and said, ""Yes, the sign says not to lay against the side rail."" Staff was informed of the resident's wish to be repositioned. Resident #44 stated she was more comfortable after she had been repositioned and her body was in better alignment. No positioning devices were used and, within approximately ninety (90) minutes, the resident had again slid over to her right. -- c) Resident #86 This resident was observed at approximately 5:30 p.m. on 05/20/09. It was noted this resident had slid down in her bed, so that her lower [MEDICATION NAME] and upper lumbar spine were where her hips should have been. On 05/20/09 at approximately 6:10 p.m., the call light was on in this resident's room. The room was entered, and the resident was engaged in conversation. She said she had been lying like that for a while. When asked whether she was comfortable, she said, ""No, my back hurts."" At 6:19 p.m., a staff member entered the room to see what the resident who had rung the call bell needed. The staff member left the room without offering to reposition Resident #44. At approximately 6:30 p.m., staff was informed the resident needed to be repositioned. At approximately 7:00 p.m., the resident was asked whether being repositioned had helped her back, and she said it had. -- d) Resident #47 This resident was observed during wound care rounds on 05/20/09. She was sitting in a wheelchair with a soft cushion behind her back. The resident had severe kyphosis. She had one (1) area on her spine with scar tissue from a recently healed pressure area. Another area on her spine was still open and being treated. Review of the resident's medical record found the physician had written the following order on 05/07/09: ""Obtain foam pillow /c (with) window cut in center to put behind her [MEDICATION NAME] spine when sitting."" The corresponding physician's progress note identified the resident had a 1 cm pressure ulcer on the [MEDICATION NAME] spine which was improving. The plan was to improve padding to relieve pressure. The cushion that was observed did not have a window cut out for the [MEDICATION NAME] spine as ordered. In exit conference, the medical director, who had also made wound care rounds on 05/20/09, noted the soft pillow that had been put behind the resident. She agreed, however, that the attending physician needed to be made aware and to change the order if desired. -- e) Resident #53 The medical record review for Resident #53, conducted on 05/20/09 at approximately 1:00 p.m., revealed the physician had written an order, dated 04/28/09, for the resident to have a pressure reducing device in her chair. On 05/20/09 at approximately 10:30 a.m., the resident did not have a pressure reducing cushion in her chair. The administrator was made aware of this observation at approximately 5:00 p.m. on 05/20/09. .",2014-11-01
10951,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,310,E,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observations during meal times, the facility failed to ensure a resident's ability to eat did not diminish unless the individual's clinical condition made the diminution unavoidable. Residents were not seated and/or positioned to enable them to feed themselves with optimal comfort and ease. Eight (8) residents were observed to be in need of repositioning and/or changes in the height of the surface on which their meals were served relative to their bodies. Resident identifiers: #59, #64, #38, #1, #19, #54, #2, and #44. Facility census: 86. Findings include: a) Resident #59 At approximately 12:40 p.m. on 05/20/09, the resident was seated at a round table with three (3) other residents in the first floor dining room. The resident was seated in a reclining geri-chair. The top of the table was at the level of the resident's axilla. This resident was observed during the evening meal, at approximately 6:05 p.m., in the first floor dining room. She was seated in a geri-chair, and her meal tray had been placed on a table. The height of the table relative to her chair resulted in her plate being at the height of the base of her neck. b) Resident #64 On 05/20/09, this resident was observed at approximately 12:40 p.m. while eating in the first floor dining room. Her meal was at the height of the resident's axillary region. c) Resident #38 During lunch on 05/20/09, the resident was observed in her bed eating lunch. The head of her bed had been elevated to almost 90 degrees, and she had slid down in the bed until her subscapular region was resting near where her hips should have been in the angle of the bed. Her right shoulder was lower than the left. She was trying to eat with her left hand. It was noted she had not touched her Jello. When asked, she said she did not know it was there. At that time, Employee #97 entered the room, moved the bowl of Jello nearer to the resident, and told her it was Jello with bananas. The resident began to eat the Jello after it she had been made aware of its presence and was able to reach the item. d) Resident #1 On 05/20/09, this resident was observed eating while lying in bed. The head of her bed was elevated at approximately 70 degrees. The resident was lying on her right side and trying to eat with her dependent right hand. e) Resident #19 This resident was observed at lunch time on 05/20/09. She was lying in bed with a pillow behind her head resulting an elevation of approximately 45 degrees. This did not facilitate ease in feeding herself. f) Resident #54 At lunch on 05/20/09, the resident was observed in her room. She was in bed and had slid down so her back was bent in the lumbar-[MEDICATION NAME] area. When asked whether she was comfortable, she said, ""No."" She said, ""Yes"", when asked whether she needed to be pulled up in bed. When asked if she would like staff to be informed of her need to be repositioned she said, ""Yes"", then added, ""You can try"", when advised this surveyor would let staff know of her need. Staff did reposition the resident shortly thereafter. Approximately fifteen (15) minutes later, the resident was asked whether she was more comfortable, she said she was. g) Resident #2 A nursing assistant was observed feeding this resident who was in bed, at approximately 6:15 p.m. on 05/20/09. The resident was lying on her right side at approximately 45 degrees. The nursing assistant was sitting on the resident's left side. The resident had to turn her head to receive her food. This did not facilitate the resident's ability to swallow, as her head and neck were turned instead of being in a straight line. h) Resident #44 On 05/20/09, the resident was feeding her self her evening meal. Her head, neck, and torso had slid to the right side of her bed. She was using her right hand to feed herself, but she had to keep her elbow against the bed to keep from sliding further to the right. .",2014-11-01
10952,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,371,F,0,1,T34S11,"Based on observations made during the initial tour of the facility's kitchen and staff interview, the facility failed to store and prepare foods under sanitary conditions. A dented can was noted in the dry storage area, and equipment used to prepare food was noted to be in need of cleaning. This had the potential to affect any resident who received foods from the kitchen. Facility census: 86. Findings include: a) During the initial tour of the kitchen, a #10 can of peaches was noted on the shelf in the dry storage area. The can had a dented area involving the rim of the can and another dent greater than 45 degrees near the bottom of the can. Employee #64, when asked how dented cans were handled, said they were returned to the vendor. The can of peaches should not have been on the shelf. b) The Hobart floor stand mixer was noted to have bits of food hanging off of the head of the machine and food debris on the outside of the vessel. c) The Robot Coupe was noted to have the lid placed on the container in the closed position. There was moisture inside of the container, and a small bit of meat was adhering to the inside of the container. .",2014-11-01
10953,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,441,E,0,1,T34S11,"Based on observations, the facility's infection control program was not effective in ensuring staff practiced aseptic techniques during dressing changes. The nurse removed a pen from her pocket after donning gloves, then had direct contact with the resident's wound; 4 x 4s came in direct contact with a can of saline spray used for multiple residents; a Sharpie was place on the clean field; and a measuring device was placed directly against a wound after having been placed on the resident's bed. Resident identifiers: #9, #47, #40, and #11. Facility census: 86. Findings include: a) Resident #9 On 05/20/09 at 7:50 a.m., a nurse (Employee #10) was observed providing care to a wound on the resident's right medial ankle. The nurse donned gloves then removed a pen from her uniform pocket. While wearing the same gloves, she had contact with the wound area. This created a potential to transfer organisms from her pocket and the pen to the resident's wound. When cleansing the wound, the nurse sprayed saline onto the sponges with her left hand. After moistening the sponges, she transferred them from her right hand to the left hand and cleansed the wound. The can of saline spray had been on the treatment cart and had been used for other residents. When the nurse transferred the sponges from her right hand to her left, a potential for transfer of organisms from the can to the resident's wound was created. b) Resident #47 Employee #10 was observed providing care to an open area on the resident's spine in the morning on 05/20/09. She sprayed Wound Wash Saline onto some gauze (4 x 4s), then allowed the 4 x 4s to come in contact with the can of spray. c) Resident #40 On the morning of 05/20/09, Employee #10 provided care to the resident's wound. Again the can of saline spray came in contact with the clean 4 x 4s. d) Resident #11 During the treatment procedure for this resident on the morning of 05/20/09, Employee #10 place a Sharpie she had removed from her pocket on her dressing field. The Sharpie would be considered a contaminated item. Additionally, the plastic sheet used to measure the resident's wound was placed on the bed, then placed directly against the wound. .",2014-11-01
10954,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,492,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure determinations of incapacity were completed in accordance with the requirements of the West Virginia Code (Chapter 16 Article 30) and Physician order [REDACTED].?[DATE]. Three (3) of the fifteen (15) current residents on the sample were affected. Two (2) residents had been determined to lack the capacity to make medical decisions, but the determinations did not identify the nature of the incapacity and/or only included a [DIAGNOSES REDACTED]. One (1) resident's POST form had not been completed in accordance with the form's instructions. Resident identifiers: #20, #14, and #57. Facility census: 86. Findings include: a) Resident #20 The POST form, as specified in ?[DATE] of the West Virginia Code, includes the following instruction in Section F: ""If I lose decision-making capacity, I authorize my medical power of attorney representative / health care surrogate to make all medical decisions for me, including those regarding CPR and other life-sustaining treatment and to complete a new form. (Initials in box indicate patient acceptance of this statement)."" The form signed by the resident, on [DATE], had a check mark in the box instead of the resident's initials as specified on the form. The initials were intended to verify the resident had made the choice to allow another to change his or her wishes should he or she no longer be able to express his or her wishes regarding end of life care. b) Resident #14 Review of the resident's determination of incapacity dated [DATE] found the only cause listed was ""Dementia"". There was no additional informations provided to indicate how advanced the resident's dementia was to establish she was no longer capable of making decisions on her own behalf. Additionally, under the section ""Nature"" nothing had been checked. The West Virginia Code includes the following: ""?[DATE]. Determination of incapacity. ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known."" .",2014-11-01
10955,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,514,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the clinical record of each resident was accurate and complete. One (1) resident was listed as living in another facility on the face sheet. Another resident had an order for [REDACTED]. Two (2) of fifteen (15) current residents on the sample were affected. Resident identifiers: #45 and #68. Facility census: 86. Findings include: a) Resident #68 According to nursing entries, contact isolation was ordered for this resident on 02/06/09, but the order was not written until sometime between 02/16/09 and 02/19/09. When the order was written, it was noted as being late, but no specific date was included in the order. Review of the nursing entries, between 02/06/09 and 02/19/09, did not find any evidence the resident had been placed on contact precautions other than the one (1) entry made by the nurse who later wrote the order. b) Resident #45 During the medical record review for Resident #45 on 05/19/09, the face sheet revealed the resident's address as being that of a neighboring facility. At approximately 4:30 p.m. on 05/19/09, the administrator agreed the face sheet needed changed to reflect the resident's current address.",2014-11-01
10956,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,225,E,1,0,V0KG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and resident interview, the facility failed to report allegations of neglect; conduct an investigation of the alleged violations; and/or report the results of such investigations to State officials as required for four (4) sampled residents. Resident identifiers: #27, #30, #9, and #26. Facility census: 47. Findings include: a) Resident #27 A review of the medical record revealed Resident #27 was a self-ambulatory [AGE] year old male admitted originally on 12/28/07, and readmitted on [DATE]. A review of an event management report revealed that, at 7:25 a.m. on 06/29/11, Resident #27 was seen out of the facility ""at top of parking lot"". He had exited the facility through the therapy department's exit door. The door alarm from the resident hall into therapy had been disconnected, and no one had heard the Wanderguard alarm sound when he exited the building. Resident #27 resided in a room located approximately half-way between the exit door in question and the nurses' station. He had been identified as an exit-seeker, and his care plan stated: ""1/2/11: Wanders (behavior deterioration)."" Interventions included: ""Wanderguard alert bracelet to prevent exiting without assistance."" The resident was redirected back inside the facility by staff on 06/29/11, but this incident had a high potential for harm, as the facility is located on a curve of a highway in the direction the resident was found. This incident had not been reported to the appropriate State agencies as an allegation of neglect, and there was no evidence that an investigation had been undertaken, although it was known that the door alarm had been disabled. There was no evidence the identity of the person disabling the alarm was sought. During an interview with the administrator and the director of nurses (DON) at 3:00 p.m. on 07/13/11, the DON stated she had started an investigation, but she acknowledged the event had not been reported. She could not produce any evidence of an investigation. -- b) Resident #30 A review of the medical record revealed Resident #30 was an [AGE] year old male admitted to the facility on [DATE]. At the time of admission, he was ordered a ""Pureed Diabetic Diet"". His interim care plan, dated 06/01/11, indicated that he was ""Total assist for eating"". The dietary order form stated: ""7/1/11 Continue previous plan for diet modification, add nosey cup ... thickened liquids. Must be in room and at all meals."" Review of an event management report revealed that, on 06/29/11, this resident choked on a hot dog (received whole) while eating lunch with his wife and daughter. Although he was able to cough it out, this incident had a high potential for harm. The record showed the resident had been treated for [REDACTED]. There was no evidence to reflect this incident had been reported to the appropriate State officials or that an investigation had been done to determine why and by whom the resident had been fed food other than the pureed diet ordered by his physician. During an interview with the administrator and the DON at 3:00 p.m. on 07/13/11, the DON stated she had started an investigation, but she could produce no written evidence of this. She acknowledged the incident had not been reported. -- c) Resident #9 A review of the facility complaint files, on the morning of 07/13/11, revealed two (2) complaints filed by Resident #9's medical power of attorney (MPOA). 1. One (1) complaint, received by received by the assistant director of nursing (ADON - Employee #73) on 07/02/11, stated (quoted as written): ""... (Employee #46) CNA was very rude to her grandmother (Name of Resident #9). Interviewed (Resident #9) and she stated 'She told me I should be able to wheel myself back to my room and I can't do that.' Also states she was very rude. Granddaughter & Resident both tearful & upset. When (Employee #46) walked into rm (room). (Resident #9) pointed @ (at) her & said 'that's the one.' (Employee #46) attempted to try to Explain what happened but granddaughter asked (Employee #45) to leave the room."" No further investigation was noted, and this complaint (which contained an allegation of abuse / mistreatment) was not reported to any State agencies. The facility's employee list revealed Employee #46 was a registered professional nurse (RN). In the early afternoon of 07/13/11, this surveyor asked for the facility's complaint records, which the administrator retrieved from his desk. In an interview conducted with the DON and the administrator on the morning of 07/13/11, the DON said complaints had been given to the administrator for investigation. The administrator stated, ""I was out last week with pneumonia."" The administrator further stated, ""I did get a statement from (Employee #46)."" The administrator did not produce this statement at the time of exit. - 2. Another complaint, filed with the ADON by Resident #9's MPOA on 07/03/11, stated (quoted as written), ""Does not want (Employee #43) to care for her states 'he's always complaining & moody.'"" No further information was noted on the complaint form, and this complaint was not reported to any State agencies. An ""FYI"" (for your information) notice that was posted at the nurses' station contained the following information: ""... - (Employee #43) is not to have (Resident #6), (Resident #9), (Resident #36)."" The FYI was not signed nor dated. -- d) Resident #26 In the early afternoon of 07/13/11, this surveyor asked for the facility's complaint records which the administrator retrieved from his desk. The following statement, dated 07/08/11, was written and signed by a licensed practical nurse (LPN - Employee #16) who was the treatment nurse (quoted as written): ""I came up to the desk before the start of my shift. (Employee #43) came & asked for a bandaid. The scab came off (Resident #26's) L (left) knee. Told him I didn't know (Resident #26) had a scab on his knee. He got louder wanting a bandaid asking 11-7 nurse (Employee #3) to get him one. ""I told (Employee #43) he needed to calm down I would go look at (Resident #26). Told him he needed to fill out a skin care alert sheet & give to (Employee #3). ""Went to room (Employee #43) showed me a scab on a wash cloth that was smaller than skin tear on L (left) knee which was 1 x 1 cm. (Resident #26) was upset, cursing attempting to hit at staff. Treatment was started to area. ""When I went into his room later to do treatment on his L foot. I asked (Resident #26) when he was so upset /c (with) (Employee #43). (Resident #26) stated 'he throws me around. I want him to stay the hell out of here.' ""I don't know what happened in the room before I went in to do treatment to the area on (Resident #26's) knee. (Resident #26) is known to curse & resist care."" There was no further documentation on a complaint form, nor was Employee #43 (a nurse aide) reported to any State agency. In an interview conducted with the DON and the administrator at 3:15 p.m. on 07/13/11, the DON stated, ""I will report rather late than not at all. I gave it to him (administrator)."" The administrator had no comment. The DON said that social services was aware of the complaints. Reporting forms were brought to this meeting by an RN (Employee #5). These were found in the back of a file cabinet at the nurses' station. .",2014-11-01
10957,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,500,E,1,0,V0KG11,". Based on a review of the agreements with attending physicians and staff interview, the facility failed to ensure the attending physician for five (5) of forty-seven (47) residents in the facility made arrangements specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services and the timeliness of the services. Resident identifiers: #19, #34, #12, #10, and #6. Facility census: 47. Findings include: a) Residents #19, #34, #12, #10, and #6 Review of the facility's written agreements and contracts failed to find evidence that the attending physician for Residents #6, #10, #12, #19, and #34 had a written agreement with the facility that ensured he would provide services for the residents (including those with respect to supervision of care, review of care, notes, and orders at each visit, and frequency and timeliness of visits). The contract book only contained copies of the physician's license and proof of medical liability insurance. An interview with the director of nursing, on 07/12/11 at 4:00 p.m. found she did not believe the physician needed an agreement with the facility and that the facility only required proof of his license and insurance. .",2014-11-01
10958,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,501,F,1,0,V0KG11,". Based on policy review, review of medical director's contract, and staff interview, the facility failed to ensure the medical director was involved in implementation of care policies and the coordination of medical care in the facility. This has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from ""Med Path"", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or the drug formulary were ever reviewed or revised after the initial signature date of 09/28/09. The formulary in this manual was not the drug formulary in use by the facility. This was verified by the DON at 2:00 p.m. on 07/13/11, when she produced the drug formulary currently in use. - The DON also produced a Long Term Care Facility's Pharmacy Services and Procedure Manual from Omnicare, Inc. (the facility's contracted pharmacy vendor) dated May 2010. She stated that Omnicare provided an updated manual every year. This manual had a cover page with allowed for the recording of the signatures of the administrator, DON, medical director, and consultant on an annual basis. There were no signatures on the sheet to indicate when this manual's contents had been reviewed, adopted, or revised. There were two (2) pharmacy manuals from previous years located in the DON's office, but neither of these contained any evidence of them having been reviewed / adopted for use. - During an interview with the certified dietary manager at 8:45 a.m. on 07/13/11, she produced an up-to-date dietary resource manual published by the Iowa Dietetic Association, but when asked about facility-specific dietary department policies, she stated they were in the ""Facility Policy Manual"" which was maintained by the DON. The facility's policies regarding dietary service was requested from the DON at 9:40 a.m. on 07/13/11. She stated, ""There is no hard copy."" She then brought up on the computer a generic policy / procedure manual from a website titled ""Emeritus Senior Living"". There was no identification of The Heritage, Inc. as an included entity, and none of the policies were identified as long term care (nursing home) policies. - In an interview with the DON at 8:00 a.m. on 07/13/11, she deferred to the administrator for any governing body questions or administrative facility policies. - During an interview with the administrator at 9:15 a.m. on 07/13/11, he confirmed there was no hard copy of the facility's policies, that most of the policies were available ""on-line on the computer"". He further stated, ""Emeritus, that owns the facility, had previously only governed assisted living facilities and is slowly getting caught up to LTC requirements."" The administrator was asked to provide any policies that addressed the distinct population or environment of this facility and/or evidence that anyone (e.g., the facility's board of directors, himself, the medical director, or any committee) had initially reviewed, approved and/or revised any of the policies addressing resident care or the day-to-day operation for this facility. He acknowledged the request, but prior to exit, he offered none of these things except the following: - A copy of his job description, which included the following under the heading ""Essential Functions"": ""Ensure safety of residents, their visitors and staff regarding Infection Control, Fire, and Safety policies and procedures"" ""Maintain current knowledge of State Regulations and ensure compliance in all surveys conducted by licensing authority"" - A mission statement from Emeritus Senior Living, which stated: ""It is our goal to continually exceed the expectations of our residents, families, and employees by immediately addressing issues in a professional manner and constantly striving to deliver the highest level of customer value through exceptional quality service."" (See also citation at F493.) - In a second interview with the DON and the administrator at 3:00 p.m. on 07/13/11, in the presence of the entire survey team, they were again asked for any evidence that the facility's policies had been reviewed / approved and by whom. The administrator had no comment. - Review of the contract between the medical director and the facility found the following duties: ""Review policies, procedures, and and guidelines to ensure adequate, comprehensive services for the Residents of the (facility). ..."" ""To attend scheduled monthly and quarterly / annual administrative and/or quality assurance ..."" An interview with the DON, on 07/13/11 at 4:00 p.m., found the medical director only attended one (1) quality assurance meeting and she wondered how to communicate with him regarding quality assurance activities. - Further review of the facility's policies and procedures found no evidence the medical director reviewed any of the resident care policies. .",2014-11-01
10959,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,441,D,1,0,V0KG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to implement infection control practices for one (1) of five (5) residents reviewed who had been diagnosed with [REDACTED]. The resident had a recently diagnosed urinary tract infection, and direct care staff was not aware of this infection. Resident identifier: #30. Facility census: 47. Findings include: a) Resident #30 Review of the medical record for Resident #30, on 07/13/11, noted the resident had recently been treated for [REDACTED]. treatment for [REDACTED]. There had been no repeat lab studies to indicate the successful treatment of [REDACTED]. - A nursing assistant who was providing direct care for this resident on 07/13/11 (Employee #30), when asked if she was aware of any precautions related to the care of this resident, stated she was not. - The facility's policy / procedure related to care of residents with an MDRO was requested and received from the facility's director of nursing (DON) on the afternoon of 07/13/11. Review of this policy / procedure (which was not dated to indicate when it was adopted or revised by the facility) disclosed the following directives at Item #28: ""Notify physicians and other healthcare personnel who provide care for the resident that the resident is colonized / infected with a multidrug-resistant organism."" - The DON, when interviewed on 07/13/11 at 2:00 p.m., stated the resident had an indwelling urinary catheter and the source of the infection was contained. The DON could not, however, provide evidence that direct care staff was made aware of this resident's infection, as stated in facility policy / procedure. .",2014-11-01
10960,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,504,D,1,0,V0KG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to obtain a physician-ordered lab study. A resident exhibiting signs and symptoms of a urinary tract infection received a physician's orders [REDACTED]. The physician ordered that the specimen be recollected and submitted for testing. This second submission was not completed. Resident identifier: #6. Facility census: 47. Findings include: a) Resident #6 The medical record of Resident #6, when reviewed on 07/13/11, disclosed this [AGE] year old female had resided at the facility for quite some time but had recently been hospitalized and returned to the facility on [DATE]. The resident's had been hospitalized with a [MEDICAL CONDITIONS] - a blood clot in a deep vein of the leg. Additional medical [DIAGNOSES REDACTED]. - Shortly following her return to the facility, on 06/23/11 at 10:15 am, a nurse documented the following: ""Resident c/o (complained of) back of head hurting and dizzy. Dr. (name) was present in the house. B/P (blood pressure) for this resident 110/60, blood sugar 299. Temp (temperature) 98.1 afebrile. After sitting for a while resident felt better. Resident unable to finish therapy session due to being tired."" Following this incident on this same day (06/23/11), the resident's daughter requested a urinalysis be completed, and the attending physician gave an order for [REDACTED]. A urine specimen was collected and tested via ""dip-stick"" by facility staff. A nurse's note, dated 06/23/11 at 12:40 p.m., stated, ""Urine obtained via clean catch and dipstick (+) (positive) for leukocytes."" The entry further stated that the lab would pick up the urine specimen that day. A nurse's note, dated 06/28/11 at 4:30 p.m., stated, ""Dr (name) notified of C&S (culture and sensitivity) report and orders received to repeat C&S."" Review of the lab report related to this sample disclosed the urine specimen was contaminated. - Continued review of the resident's nursing notes revealed the following entries related to the resident's physical condition: - On 06/29/11 at 21:30 (9:30 p.m.) - ""Evening fingerstick read 'high'."" - On 07/03/11 at 21:45 (9:45 p.m.) - ""Res. (resident) daughter (daughter's name) stating 'mom is sick and vomiting'. FSBS (fingerstick blood sugar) check. Results 585."" - On 07/07/11 at 8:40 p.m. - A nurse again noted the resident's blood sugar fingerstick registered ""high"" when tested . The elevated blood sugar levels were treated on each occasion, but the medical record disclosed no evidence that staff attempted to determine the cause of the excessively high levels or to rule out the possibility of a urinary tract infection and to repeat the urine testing as ordered by the physician. - On 07/08/11 at 10:40 a.m., a nurse's note stated she had spoken to the resident's daughter and reported a morning fingerstick of 366 and dip stick results indicating a urine infection. This nurse then called the physician and waited for a return call for orders. (The resident's physician had previously given an order for [REDACTED]. At 11:05 a.m. on 07/08/11, according to nurse's notes, the resident experienced a [MEDICAL CONDITION] in the dining room and was unresponsive. Testing at that time disclosed the resident's fingerstick blood sugar was ""too high to read"". The resident was transported to the hospital at that time. - The urine testing that had been ordered on [DATE] had never been completed, and this was confirmed by the director of nursing (DON), when interviewed at approximately 2:00 p.m. on 07/13/11. - The resident's medical records from the hospital, where she currently was a patient, were requested and received. A medicine progress note, dated 07/11/11, stated, ""Her worsening mental status could be secondary to her UTI (urinary tract infection). Her new onset [MEDICAL CONDITION] ? (questionable) etiology, possibly related to [MEDICAL CONDITION] ? (questionably) related to UTI."" The available hospital information did state the resident's urine culture displayed greater than 100,000 colonies/ml [MEDICATION NAME] species with identification and susceptibilities not available to this reviewer. The resident was currently being treated at the hospital with intravenous antibiotics for this urinary tract infection. (See also citation at F309.) .",2014-11-01
10961,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,493,F,1,0,V0KG11,". Based on policy review and staff interview, the governing body failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical well-being of each resident. A commercially-published nursing service policy manual was not reviewed, revised to reflect facility-specific activities, and formally adopted for use by the facility's administrative staff (including the administrator). The drug formulary found in the pharmacy manual was not the formulary currently in use. The dietary department policy manual was kept in the director of nursing (DON) office. Policy / procedure manuals from the facility's corporation were available on-line but were not revised to reflect facility-specific requirements or printed and/or otherwise available / accessible to staff for day-to-day use. In general, the policies and procedures intended to guide staff in the rendering of resident care / services and the day-to-day operations of this facility were not approved / adopted and readily available for use by staff. This practice has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from ""Med Path"", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or the drug formulary were ever reviewed or revised after the initial signature date of 09/28/09. The formulary in this manual was not the drug formulary in use by the facility. This was verified by the DON at 2:00 p.m. on 07/13/11, when she produced the drug formulary currently in use. - The DON also produced a Long Term Care Facility's Pharmacy Services and Procedure Manual from Omnicare, Inc. (the facility's contracted pharmacy vendor) dated May 2010. She stated that Omnicare provided an updated manual every year. This manual had a cover page with allowed for the recording of the signatures of the administrator, DON, medical director, and consultant on an annual basis. There were no signatures on the sheet to indicate when this manual's contents had been reviewed, adopted, or revised. There were two (2) pharmacy manuals from previous years located in the DON's office, but neither of these contained any evidence of them having been reviewed / adopted for use. - During an interview with the certified dietary manager at 8:45 a.m. on 07/13/11, she produced an up-to-date dietary resource manual published by the Iowa Dietetic Association, but when asked about facility-specific dietary department policies, she stated they were in the ""Facility Policy Manual"" which was maintained by the DON. The facility's policies regarding dietary service was requested from the DON at 9:40 a.m. on 07/13/11. She stated, ""There is no hard copy."" She then brought up on the computer a generic policy / procedure manual from a website titled ""Emeritus Senior Living"". There was no identification of The Heritage, Inc. as an included entity, and none of the policies were identified as long term care (nursing home) policies. - In an interview with the DON at 8:00 a.m. on 07/13/11, she deferred to the administrator for any governing body questions or administrative facility policies. - During an interview with the administrator at 9:15 a.m. on 07/13/11, he confirmed there was no hard copy of the facility's policies, that most of the policies were available ""on-line on the computer"". He further stated, ""Emeritus, that owns the facility, had previously only governed assisted living facilities and is slowly getting caught up to LTC requirements."" The administrator was asked to provide any policies that addressed the distinct population or environment of this facility and/or evidence that anyone (e.g., the facility's board of directors, himself, the medical director, or any committee) had initially reviewed, approved and/or revised any of the policies addressing resident care or the day-to-day operation for this facility. He acknowledged the request, but prior to exit, he offered none of these things except the following: - A copy of his job description, which included the following under the heading ""Essential Functions"": ""Ensure safety of residents, their visitors and staff regarding Infection Control, Fire, and Safety policies and procedures"" ""Maintain current knowledge of State Regulations and ensure compliance in all surveys conducted by licensing authority"" - A mission statement from Emeritus Senior Living, which stated: ""It is our goal to continually exceed the expectations of our residents, families, and employees by immediately addressing issues in a professional manner and constantly striving to deliver the highest level of customer value through exceptional quality service."" - In a second interview with the DON and the administrator at 3:00 p.m. on 07/13/11, in the presence of the entire survey team, they were again asked for any evidence that the facility's policies had been reviewed / approved and by whom. The administrator had no comment. .",2014-11-01
10962,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-07-13,520,F,1,0,V0KG11,". Based on policy review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware and develop / implement appropriate plans of action to correct these quality deficiencies. The facility's QAA committee failed to identify that policies and procedures intended to guide the rpovision of resident care and services and the day-to-day operations of the facility were not reviewed, adopted, revised (when applicable) by administrative staff (including the director of nursing, administrator, and medical director), nor did the QAA committee identify the need to make these policies and procedures available / accessible for use by staff. These quality deficiencies had existed since a change occurred in the facility governing body in July 2010, and no plan had been instituted to correct them. this practice has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from ""Med Path"", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or the drug formulary were ever reviewed or revised after the initial signature date of 09/28/09. The formulary in this manual was not the drug formulary in use by the facility. This was verified by the DON at 2:00 p.m. on 07/13/11, when she produced the drug formulary currently in use. - The DON also produced a Long Term Care Facility's Pharmacy Services and Procedure Manual from Omnicare, Inc. (the facility's contracted pharmacy vendor) dated May 2010. She stated that Omnicare provided an updated manual every year. This manual had a cover page with allowed for the recording of the signatures of the administrator, DON, medical director, and consultant on an annual basis. There were no signatures on the sheet to indicate when this manual's contents had been reviewed, adopted, or revised. There were two (2) pharmacy manuals from previous years located in the DON's office, but neither of these contained any evidence of them having been reviewed / adopted for use. - During an interview with the certified dietary manager at 8:45 a.m. on 07/13/11, she produced an up-to-date dietary resource manual published by the Iowa Dietetic Association, but when asked about facility-specific dietary department policies, she stated they were in the ""Facility Policy Manual"" which was maintained by the DON. The facility's policies regarding dietary service was requested from the DON at 9:40 a.m. on 07/13/11. She stated, ""There is no hard copy."" She then brought up on the computer a generic policy / procedure manual from a website titled ""Emeritus Senior Living"". There was no identification of The Heritage, Inc. as an included entity, and none of the policies were identified as long term care (nursing home) policies. - In an interview with the DON at 8:00 a.m. on 07/13/11, she deferred to the administrator for any governing body questions or administrative facility policies. - During an interview with the administrator at 9:15 a.m. on 07/13/11, he confirmed there was no hard copy of the facility's policies, that most of the policies were available ""on-line on the computer"". He further stated, ""Emeritus, that owns the facility, had previously only governed assisted living facilities and is slowly getting caught up to LTC requirements."" The administrator was asked to provide any policies that addressed the distinct population or environment of this facility and/or evidence that anyone (e.g., the facility's board of directors, himself, the medical director, or any committee) had initially reviewed, approved and/or revised any of the policies addressing resident care or the day-to-day operation for this facility. He acknowledged the request, but prior to exit, he offered none of these things except the following: - A copy of his job description, which included the following under the heading ""Essential Functions"": ""Ensure safety of residents, their visitors and staff regarding Infection Control, Fire, and Safety policies and procedures"" ""Maintain current knowledge of State Regulations and ensure compliance in all surveys conducted by licensing authority"" - A mission statement from Emeritus Senior Living, which stated: ""It is our goal to continually exceed the expectations of our residents, families, and employees by immediately addressing issues in a professional manner and constantly striving to deliver the highest level of customer value through exceptional quality service."" (See also citation at F493.) - In a second interview with the DON and the administrator at 3:00 p.m. on 07/13/11, in the presence of the entire survey team, they were again asked for any evidence that the facility's policies had been reviewed / approved and by whom. The administrator had no comment. - Review of the contract between the medical director and the facility found the following duties: ""Review policies, procedures, and and guidelines to ensure adequate, comprehensive services for the Residents of the (facility). ..."" ""To attend scheduled monthly and quarterly / annual administrative and/or quality assurance ..."" - Further review of the facility's policies and procedures found no evidence the medical director reviewed any of the resident care policies. (See also citation at F501.) - An interview with the DON, on 07/13/11 at 4:00 p.m., found the medical director only attended one (1) quality assurance meeting and she wondered how to communicate with him regarding quality assurance activities.",2014-11-01
10692,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,157,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to immediately notify an interested family member when one (1) of forty-five (45) Stage II sample residents, who was alert and oriented, experienced an acute change in condition resulting in transfer to a local hospital emergency department. Resident identifier: #162. Facility census: 105. Findings include: a) Resident #162 On 08/08/11 at approximately 1:00 p.m., medical record review for Resident #162 revealed he had the capacity to make his own medical decisions. The review also revealed two (2) nursing notes pertaining to an acute change in the resident's physical condition. - A nursing note, dated 07/04/11 at 12:15 p.m., stated: ""Called (physician name) on his cell phone. Rec'd (received) order to send to ER (emergency room ) for eval (evaluation) 911 called. Res (resident) sent via stretcher with 2 attendants noted to have left side weakness and slight facial droop. Remains alert and responsive. 02 NC (nasal cannula) on with 02 sat 92-94. Ambulance personnel failed to take med (medical) records packet (transfer, md orders and d/c summary with them)."" - A nursing note, dated 07/04/11 at 17:05 (5:05 p.m.), stated, ""This nurse informed (resident's sister's name) that res. was transferred to (name of hospital) for eval (evaluation) at approx (approximately) 12:15 p.m. Res. sister approached this nurse to ask if res. (resident) had gone to ER. This nurse informed her 'yes.' Call placed to (name of hospital) ER. Res. has been admitted to (name of hospital) for [MEDICAL CONDITION] and [MEDICAL CONDITION] ischemia. Sister completely updated on status."" On 08/08/11 at approximately 2:00 p.m., the director of nursing (DON - Employee #27A) reviewed the nursing notes in the medical record and reported her belief that the family had received notification of the resident's change in condition. She also felt that the resident's capacity status relieved the facility of any further duties regarding notification. However, the nursing notes did not indicate the resident's sister had received notification on 07/04/11 at 12:15 p.m., when her brother experienced the change in condition and required transfer to the hospital. The nursing notes reflected the resident's sister did not receive notification of his transfer until approximately 5:05 p.m. on 07/04/11. .",2014-12-01
10693,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,272,E,1,1,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, resident interview, family interview, and staff interview, the facility failed to assure ongoing, accurate comprehensive assessments for six (6) of forty-five (45) Stage II sample residents. There was a failure to accurately assess for falls for two (2) residents, a failure to accurately assess for pain for one (1) resident, a failure to accurately assess for toileting needs for one (1) resident, a failure assess bruising for one (1) resident, and a failure to accurately assess the amount of staff assistance needed at meals for three (3) residents. Resident identifiers: #37, #1, #71, #128, #125, #214, and #159. Facility census: 105. Findings include: a) Resident #37 Record review revealed this resident was admitted to the facility on [DATE]. According to an interview with a registered nurse (RN - Employee #86) on 07/26/11 at 9:53 a.m., the resident fell on [DATE] and sustained no injuries. Further medical record review, on 08/02/11, revealed the resident also fell without injuries on 04/19/11, 04/20/11, 07/02/11, 07/06/11, and 07/27/11. Review of the resident's re-admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/04/11, found the assessor indicated, at G0110E and G0110F (relative to locomotion in the room and off the unit), the resident was independent in these areas and needed no staff assistance. This was not accurate, as evidenced by the falls the resident had in his room as well as in another part of the facility on 07/04/11. -- b) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not offered assistance prior to removal of her meal. The hallway outside of the resident's room was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the meal tray was removed from the resident's room. Review of the resident's quarterly MDS, with an ARD of 04/20/11, found the resident was coded as being independent in eating. Observation revealed this was not accurate. -- c) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her uneaten meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway outside of th resident's room was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the meal tray was removed from the resident's room. Review of the resident's quarterly MDS, with an ARD of 07/06/11, found the resident was coded as being independent in eating. Observation revealed this was not accurate. -- d) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to deuteron if she needed assistance. The hallway outside of the resident's room was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the meal tray was removed from the resident's room. Review of the resident's unscheduled MDS, with an ARD of 07/07/11, found the resident was coded as being independent in eating. Observation revealed this was not accurate. -- e) Resident #125 At 11:34 a.m. on 07/26/11 (during Stage I of the survey), a large bruise was noted on the resident's left arm. Upon inquiry, the resident stated he did not know what had happened. He said he just got up one morning and it was there. The bruise was observed again at 8:30 a.m. on 08/09/11 (during Stage II of the survey). The resident's annual MDS, with an ARD of 07/28/11, was reviewed. The assessor did not encode the presence of a non-pressure related bruise at that time. The medical record, when reviewed, contained no evidence the bruise had been identified or assessed by nursing. On 08/09/11 at 9:00 a.m., this area was observed with a registered nurse (RN) consultant (Employee #28A). Employee #28A stated she would investigate whether this bruise had been identified and assessed by staff. At 10:05 a.m. on 08/09/11, Employee #28A reported this area had not been identified or assessed by the facility. -- f) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED]."". According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or whether she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound VAC to measure and apply a new dressing. The wound VAC dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her Medication Administration Record [REDACTED].) On 07/24/11, nursing notes stated: ""S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. A nursing note, on 07/25/11, recorded receipt of new orders for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 25 mg BID (twice daily) for [MEDICAL CONDITION]. There was no documentation to reflect the resident was exhibiting signs or symptoms of [MEDICAL CONDITION], nor was there evidence to reflect staff had assessed the resident for pain. -- 2. Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. -- 3. On 07/27/11, the resident's medical record was reviewed for documentation of the factors surrounding this resident's falls. There was no contemporaneous entry in the nursing notes to correspond with the fall on 07/26/11, and there was no evidence to reflect staff conducted a physical assessment of the resident and no evidence to reflect staff conducted an investigation to identify possible [MEDICATION NAME] and/or extrinsic factors that may have contributed to this fall. The facility's incident / accident reports were reviewed, and no report was found for Resident #214's fall on 07/26/11. Additionally, ""Resident Fall Evaluation"" and ""Fall Investigation Worksheet"" forms were not completed following this fall. A nursing note, dated ""07/24/11"", stated Resident #214 had a fall on 07/26/11. This was brought to the attention of an RN nurse consultant (Employee #28A), who stated this note was probably dated incorrectly, because it was written after a note dated 07/25/11. She said this note must have been intended for 07/26/11, as the next consecutive note, dated 07/27/11, stated the resident had no further falls. Employee #28A verified there was no note in the medical record to describe the details of the fall that had occurred on 07/26/11. Employee #28A was questioned on 08/03/11 at 10:00 a.m. about the fall on 07/26/11. She did not provide evidence to reflect the resident had been thoroughly assessed after the fall or that the circumstance of the fall had been thoroughly investigated, as there was no incident / accident report, no ""Resident Fall Investigation"" form, no ""Fall Investigation Worksheet"" form, and no details about the fall recorded in the nursing notes. The facility's Fall Management Program was reviewed, and on 08/03/11 at 2:00 p.m., Employee #28A was questioned further about follow-up actions taken by staff after the fall on 07/26/11. Employee #28A did not provide evidence that all applicable post-fall actions were taken as required by the Fall Management Program. -- 4. Further record review for this resident found the Care Area Assessment (CAA) notes did not provide an additional assessment for the care areas that were triggered by the resident's most recent comprehensive MDS. The admission MDS, with an ARD of 07/31/11, indicated in Section J1700 that Resident #214 had fallen in the month prior to ARD date and before the resident's admission to this facility. Documentation in Section V of the MDS indicated the care area of ""falls"" triggered and would be addressed in the care plan. This documentation also identified the location and date of the CAA information as ""CAA WS (worksheet) dated 8/1/11"". The CAA worksheet, dated 08/01/11, for the area of falls was reviewed. The CAA notes, dated 08/01/11, listed her medications, stated that she fell at home prior to coming to the facility, that she had a bed alarm to her bed and a high low bed with safety mats at bedside due to her poor safety awareness, and that she was unable to determine the edge of the bed. There was no information contained in the CAA notes to identify that this resident had fallen twice since her admission to the facility; both falls occurred during the assessment reference period ending 07/31/11. The worksheet then provided a place to record an analysis of the findings; this analysis consisted of a paragraph restating the same information. There was no evidence of an in depth analysis of the findings (e.g., whether the use of [MEDICATION NAME] may have contributed to falls; whether untreated pain made the resident restless; whether the resident required assistance with toileting; etc.) and no explanation as to why the decision was made to proceed with care planning for falls. -- g) Resident #159 The initial nursing note, dated 06/20/11, indicated this resident was incontinent of bowel and bladder, with the family stating this was a new finding. The admission nursing assessment, dated 06/20/11, stated the resident was incontinent of bowel and bladder and she wore pads / briefs. A 3-day bowel and bladder continence evaluation was started 06/21/11, which included a 72-hour diary of the resident's bowel and bladder elimination pattern. This evaluation found the resident was clean and dry at times, incontinent of bladder at times, and incontinent of bowel at times when she was checked every hour. There was no evidence that she required or received staff assistance with toilet use. After the 72-hour diary is completed, the next step of the evaluation was to check the type of incontinence identified, after which the nurse was to sign and date the form. This section was left blank. The next step of the evaluation was to check the type of toileting program to be provided to the resident and record the reason for this choice. This section was also left blank. The last step of the evaluation was to to document interventions on the resident's care plan as applicable. This resident's bowel and bladder continence evaluation was not complete. - Review of the resident's admission + Medicare 14-Day MDS, with an ARD of 06/30/11, found the assessor recorded the resident required the extensive assistance of two (2) staff members for toilet use. The assessor also encoded the MDS to indicate the resident was always incontinent of both bowel and bladder and that the resident was not on a toileting program. The information coded in this MDS triggered the CAA for urinary incontinence. This meant the interdisciplinary team was to conduct an in depth assessment of the resident's bladder incontinence. Review of the CAA note and worksheet found no evidence of further assessment of this resident's bladder incontinence. The CAA note simply stated the resident was incontinent of bowel and bladder, which was already stated on the MDS that triggered the in depth assessment. The type of bladder incontinence was not identified, and there was no mention of the length of time the resident had been incontinent. The CAA guided the assessor to record information obtained from the resident and/or family / representative regarding this care area, but there was no evidence to reflect the assessor had interviewed the family about the incontinence. During an interview on 07/26/11 at 10:00 a.m., the resident's family reported the resident had been continent prior to her hospitalization . The family also reported that staff did not respond promptly to assist with the toileting needs of the resident. .",2014-12-01
10694,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,279,E,1,1,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to develop and/or revise the comprehensive care plans for ten (10) of forty-five (45) Stage II sample residents. The facility failed to assure each care plan was developed by the interdisciplinary team to assure each discipline had correlating goals and interventions for one (1) resident; failed to assure care plans accurately reflected activity of daily living (ADL) needs (specifically need for assistance at meal times) for three (3) residents; failed to develop a care plan for non-pressure related skin conditions (bruising) for one (1) resident; failed to develop a care plan with specific interventions to ensure adequate assessment of a resident with an acute upper respiratory infection; failed to assure a care plan with measurable goals to address pain for one (1) resident; failed to develop a care plan to improve continence for one (1) resident; failed to develop a care plan to adequately address pain for one (1) resident with a [DEVICE]-assisted closure (vac) device who was being treated with psychoactive medications for behaviors that were likely associated with pain; and failed to develop care plan on admission to address two (2) residents who were assessed at that time as having a previous history of falls prior to admission. Resident identifiers: #1, #71, #128, #37, #125, #183, #216, #159, #214, and #206. Facility census: 105 Findings include: a) Resident #37 This resident's care plan relative to nutrition was reviewed on 08/02/11. The care plans reviewed were those in a file at the nurse's station. According to the facility, these were the current care plans. Further review, on 08/03/11, revealed another nutritional care plan dated 06/27/11. This care plan was in the resident's electronic medical record but was not correlated with the hard copy care plan found at the nurses' station, where the current plans were supposed to be found. In other words, the nutritional care plan in the electronic medical record was not available for use by all staff. This care plan contained different information than the one (1) found at the nurses' station. Interview with the consultant dietitian (Employee #45), at 6:45 p.m. on 08/04/11, revealed he entered his information into the computer ""as needed"". This was discussed with Employee #80 (minimum data set (MDS) assistant) at 10:45 a.m. on 08/09/11, who revealed that changes to care plans were handwritten on the existing care plans. The care plan team did not know the consultant dietitian was entering his changes directly into the computer, as no representative from the dietary department attended care planning. This was why nursing and dietary care plans addressing nutritional needs for Resident #37 did not correlate with each other. -- b) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not offered assistance prior to removal of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. The resident's care plan, dated 05/03/11, revealed no goals or interventions relative to the resident's ability to feed herself. Observation revealed the resident was not able to feed herself after tray setup. -- c) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the tray was removed from the resident's room. The resident's care plan, dated 07/25/11, included the following goal and intervention: ""... and will continue to feed self through next review"" and ""... able to feed self after tray setup."" Observation revealed the resident was not able to feed herself after tray setup. -- d) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the tray was removed from the resident's room. The resident's care plan, dated 05/11/11, included the following goal and approach: ""... and will continue to feed self through next review"" and ""... able to feed self after tray setup."" Observation revealed the resident was not able to feed herself after tray setup. -- e) Resident #125 At 11:34 a.m. on 07/26/11, during Stage I of the survey, a large bruise was noted on the resident's left arm. Upon inquiry, the resident stated he did not know what had happened. He said he just got up one morning and it was there. The bruise was observed again, during Stage II of the survey, at 8:30 a.m. on 08/09/11. The medical record, when reviewed, contained no evidence the bruise had been identified, assessed, or care planned if needed. On 08/09/11 at 9:00 a.m., this area was observed with a registered nurse (RN) consultant (Employee #28A). Employee #28A was to investigate whether this bruise had been identified and assessed by staff. At 10:05 on 08/09/11, Employee #28A reported this area had not been identified, assessed, or care planned, if needed, by staff. -- f) Resident #183 Review of the medical record found Resident #183 was sent to an acute care facility on 07/26/11 at 5:35 p.m., for treatment related to shortness of breath, chest pain, and wheezing. She returned to the facility at 2:00 a.m. on 07/27/11 with a [DIAGNOSES REDACTED]. Review of the nursing notes from 07/27/11, 07/28/11, 07/29/11, 07/30/11, and 08/01/11 found no evidence to reflect nursing staff assessed the resident's lung sounds or respiratory status. On 08/02/11 at 7:55 a.m., the resident's oxygen saturation dropped to 77% on room air. She was transported back to the hospital at 8:07 a.m. on 08/02/11. There was no evidence to reflect nursing staff had assessed the resident's lung sounds prior to her condition declining to the point of requiring hospitalization . Review of the care plan developed for this acute condition found a goal of the resident would be free of complications related to [MEDICAL CONDITION]. The approaches included to assess the resident's lung and respiratory status as needed. The care plan did not, however, contain clear and specific instructions to direct care staff how often they were to assess the resident's lung sounds and respiratory status. -- g) Resident #216 Review of the medical record found Resident #216 was ordered [MEDICATION NAME] 5/500 mg every six (6) hours for pain. Review of the care plan found no evidence to reflect the facility had developed a comprehensive care plan with measurable goals to meet this resident's medical and nursing needs related to experiencing pain. -- h) Resident #159 The initial nursing note, dated 06/20/11, indicated this resident was incontinent of bowel and bladder, with the family stating this was a new finding. Review of the resident's admission + Medicare 14-Day MDS, with an ARD of 06/30/11, found the assessor recorded the resident required the extensive assistance of two (2) staff members for toilet use. The assessor also encoded the MDS to indicate the resident was always incontinent of both bowel and bladder and that the resident was not on a toileting program. The information coded in this MDS triggered the CAA for urinary incontinence. This meant the interdisciplinary team was to conduct an in depth assessment of the resident's bladder incontinence. Review of the CAA note and worksheet found no evidence of further assessment of this resident's bladder incontinence. The CAA note simply stated the resident was incontinent of bowel and bladder, which was already stated on the MDS that triggered the in depth assessment. The type of bladder incontinence was not identified, and there was no mention of the length of time the resident had been incontinent. The CAA guided the assessor to record information obtained from the resident and/or family / representative regarding this care area, but there was no evidence to reflect the assessor had interviewed the family about the incontinence. The decision was made to proceed with care planning urinary incontinence, with a goal of ""Improvement"". The resident's most recent care plan, when reviewed, found the problem of incontinence was briefly mentioned in relation to the resident's functional status, but there were no interventions for improving the incontinence. The skin breakdown risk care plan identified the resident had ""occasional incontinence of bowel and bladder"", which did not match the MDS that stated the resident was always incontinent of bowel and bladder. The care plan contained an intervention that stated: ""Assist with toileting prn (as needed). Resident has occasional incontinence of bowel. Encourage her to ask for assistance with toileting."" There was no plan to improve her incontinence as stated in the CAA note. -- i) Resident #214 - Pain 1. Review of the resident's physician orders [REDACTED]. - 2. During observations of this resident on 08/03/11 from 10:00 a.m. to 11:30 a.m., she was noted to be sleeping the entire time. Her lunch tray was provided to her, and at 1:15 p.m., this surveyor approached the resident. She was very lethargic, dozing off while she was eating. When interviewed by the surveyor about her meal, she reported she just wasn't very hungry. Observation found the resident wrinkling her forehead and nose and grimacing. When asked if she was having pain, she stated ""yes"". When asked to describe her pain, she stated, ""A deep pain that is real deep and sharp shooting down my leg and into my foot."" When asked what treatment she received for pain, and she stated, ""It is all right. I do not need any more pills. I take too many now."" -- 3. At 1:30 p.m. on 08/03/11, two registered nurses (RNs - Employees #9 and #28A) were asked by this surveyor to assess this resident for pain. Employee #28A asked the resident if she was hurting anywhere, and the resident stated, ""Yes. My leg hurts from here to here."" (As she spoke, the resident pointed to the area surrounding the wound vac on her left lower leg.) The RN asked her if she wanted some pain medication, and she said, ""No. I don't think I need it."" On 08/03/11, the nurse practitioner (Employee #29A) wrote a note to follow-up with the wound center as soon as possible if not already seen, and to obtain a report from the wound center if she has already been seen. Employee #29A also wrote an order for [REDACTED]."" -- 4. On 08/09/11 at 9:30 a.m., Employee #43 (a licensed practical nurse - LPN) was observed performing a treatment to Resident #214's leg. Throughout the procedure, the resident winced and gritted her teeth. At times, she covered her mouth with her sheet, and at other times, she covered her face with both hands, whimpering all the while. She repeated ""golly, golly"" time and time again. At one point, she asked the nurse to quit for a while and let her relax. It was apparent that this resident was in extreme pain, and this was confirmed by Employees #43 and #29A, who was also present at that time. Employee #29A said she would order something stronger for the resident. The treatment was stopped, and they said they were going to let the medication work before they finished the treatment. At 10:05 a.m., they administered [MEDICATION NAME] to the resident. -- 5. Review of the resident's care plan, dated 07/20/11, found the following (quoted as typed): - Problem - ""Pain / Potential for pain related to: [MEDICAL CONDITION]."" - Goals - ""Will report pain less than daily. Pain will decrease within 1 hour of intervention. Will be free from signs and symptoms of pain such as facial grimacing, moaning, or crying."" - Interventions - ""Monitor pain on scale of 1-10. Encourage resident to communicate presence of pain. Document/ report complaints & non-verbal signs of pain. Assist to reposition for comfort. Implement relaxation and/or distraction techniques to assist with pain control. Initialize Palliative Care referral. Encourage Resident to do mild exercise."" There was no recognition by staff that the resident was exhibiting signs and symptoms of pain with dressing changes. There was no plan to provide for routine pain medication and no plan to pre-medicate the resident for pain prior to completing dressing changes - such as when changing the dressing for the wound vac. -- j) Resident #214 - Falls Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED]."". Resident #214's interim care plan, which was initiated upon her admission on 07/19/11, did not address the resident's risk for falls, even though staff was aware that the resident had sustained one (1) or more falls prior to her admission. She subsequently sustained a fall on 07/23/11, after which an episodic care plan was developed to address fall prevention. -- k) Resident #206 The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled ""Determination of Capacity / Incapacity / Designated Surrogate"", which was not signed or dated. The person completing this form checked Item C ""_______ demonstrates INCAPACITY to make medical decisions"" and designated the resident's daughter to serve as health care surrogate. Upon the resident's admission to the facility, no physician's determination of capacity was made. (A form titled ""Physician's Determination of Capacity"" was found in Resident #206's medical record; it was signed by the physician and dated 07/06/11, but the form was otherwise blank - with no indication was to whether the resident did or did not possess the capacity to understand and make her own health care decisions.) On the day of her admission (06/20/11), a ""Resident Fall Evaluation"" form was completed. The assessor recorded ""Y"" for ""yes"" in response to the following questions: - ""fell in Last 30 Days?"" - ""Has there been a change in mobility?"" - ""Has there been a change in gait?"" - ""Does resident need assistance with bed mobility, transfer or ambulation?"" - ""Has resident had changes in their medication?"" - ""Is resident on any new medications?"" - ""Does resident wear glasses?"" - ""Can the resident communicate their needs?"" - ""Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?"" - Review of the resident's physician orders [REDACTED]. - 06/20/11 - ""[MEDICATION NAME] 0.5mg tab By mouth (oral) - PRN PRN: Give Q 8 hours prn - [MEDICAL CONDITION]"" - 06/21/11 - ""[MEDICATION NAME] ([MEDICATION NAME]) 1 MG Tablet By mouth (Oral) - Every four hours Everyday: Hold [MEDICATION NAME] if drowsy - Anxiety"" - Episodic care plans, dated 06/21/11, included the following problems, goals, and approaches (quoted as written): - Problem - ""(Arrow pointing down) ADL (activities of daily living), weakness, (arrow pointing down) activity tolerance, (arrow pointing down) balance, (arrow pointing down) mobility."" Goal - ""Max I (maximum independence) /c (with) ADL for safe D/C (discharge) to appropriate level of care."" Approaches - ""See HCFA 700 for POC (plan of care)."" (This care plan was written by the occupational therapist.) - Problem - ""(Arrow pointing down) cognitive skills."" Goals - ""(Arrow pointing up) cognitive skills."" Approaches - ""See HCFA 700 for POC."" (This care plan was written by the speech-language pathologist.) - Problem - ""(Arrow pointing down) bed mob (mobility), (arrow pointing down) transfer, (arrow pointing down) amb (ambulation)."" Goal - ""Safe / I to return to Home."" Approaches - ""See HCFA 700."" (This care plan was written by the physical therapist.) No care plan was developed upon admission to address the resident's risk for falls, which would have been appropriate given the [MEDICATION NAME] risk factors for falling that had been identified on the ""Resident Fall Evaluation"" form completed on the day of her admission. .",2014-12-01
10695,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,280,E,1,1,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to revise the care plans for six (6) of forty-five (45) Stage II sample residents. These residents' needs and requirements for care changed; however, the care plans were not revised to reflect the changes. When the level of staff assistance with meals changed for four (4) residents, no revisions were made to the care plans to address the increased need. There was also no revision for falls for two (2) residents. Resident identifiers: #71, #128, #1, #101, #206, and #214. Facility census: 105. Findings include: a) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her uneaten meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously, beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m., until 8:30 a.m. when the tray was removed from the resident's room. Review of the resident's care plan, dated 07/25/11, revealed the resident required tray set up and ""assistance as needed"". The Kardex, which is the plan used by nursing assistants, did not correlate with this. The Kardex noted the resident was ""independent"" with eating meals. Observation revealed the resident required more assistance than was noted in the care plan and Kardex. The care plan had not been revised to reflect the resident's current needs at mealtime. -- b) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m. when the tray was removed from the resident's room. Review of the resident's unscheduled MDS, dated [DATE], noted the resident was independent in eating. This was also noted on the Kardex used by the nursing assistants. Review of the resident's current care plan, dated 05/11/11, found the resident was able to ""feed self after tray setup"". The care plan had not been revised to reflect the resident's current needs at mealtime. -- c) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not offered assistance prior to removal of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. Review of the resident's care plan revealed no plan for assistance at meals. Additionally, the Kardex indicated the residents was independent in eating. The care plan had not been revised to reflect the resident's current needs at mealtime. -- d) Resident #101 On 08/02/11 at 8:00, this resident was observed asleep with her uneaten breakfast in front of her. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not awakened or offered assistance prior to removal of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. The resident's care plan plan was reviewed on 08/02/11. The care plan, dated 03/18/11, had an intervention to ""(a)ssist the resident with feeding PRN (as needed)."" At the time of the survey, the resident required more extensive assistance with eating than was indicated in the care plan. -- e) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled ""Determination of Capacity / Incapacity / Designated Surrogate"", which was not signed or dated. The person completing this form checked Item C ""_______ demonstrates INCAPACITY to make medical decisions"" and designated the resident's daughter to serve as health care surrogate. Upon the resident's admission to the facility, no physician's determination of capacity was made. (A form titled ""Physician's Determination of Capacity"" was found in Resident #206's medical record; it was signed by the physician and dated 07/06/11, but the form was otherwise blank - with no indication was to whether the resident did or did not possess the capacity to understand and make her own health care decisions.) On the day of her admission (06/20/11), a ""Resident Fall Evaluation"" form was completed. The assessor recorded ""Y"" for ""yes"" in response to the following questions: - ""fell in Last 30 Days?"" - ""Has there been a change in mobility?"" - ""Has there been a change in gait?"" - ""Does resident need assistance with bed mobility, transfer or ambulation?"" - ""Has resident had changes in their medication?"" - ""Is resident on any new medications?"" - ""Does resident wear glasses?"" - ""Can the resident communicate their needs?"" - ""Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?"" - Review of the resident's physician orders [REDACTED]. - 06/20/11 - ""[MEDICATION NAME] 0.5mg tab By mouth (oral) - PRN PRN: Give Q 8 hours prn - [MEDICAL CONDITION]"" - 06/21/11 - ""[MEDICATION NAME] ([MEDICATION NAME]) 1 MG Tablet By mouth (Oral) - Every four hours Everyday: Hold [MEDICATION NAME] if drowsy - Anxiety"" - Episodic care plans, dated 06/21/11, included the following problems, goals, and approaches (quoted as written): - Problem - ""(Arrow pointing down) ADL (activities of daily living), weakness, (arrow pointing down) activity tolerance, (arrow pointing down) balance, (arrow pointing down) mobility."" Goal - ""Max I (maximum independence) /c (with) ADL for safe D/C (discharge) to appropriate level of care."" Approaches - ""See HCFA 700 for POC (plan of care)."" (This care plan was written by the occupational therapist.) - Problem - ""(Arrow pointing down) cognitive skills."" Goals - ""(Arrow pointing up) cognitive skills."" Approaches - ""See HCFA 700 for POC."" (This care plan was written by the speech-language pathologist.) - Problem - ""(Arrow pointing down) bed mob (mobility), (arrow pointing down) transfer, (arrow pointing down) amb (ambulation)."" Goal - ""Safe / I to return to Home."" Approaches - ""See HCFA 700."" (This care plan was written by the physical therapist.) No care plan was developed upon admission to address the resident's risk for falls, which would have been appropriate given the [MEDICATION NAME] risk factors for falling that had been identified on the ""Resident Fall Evaluation"" form completed on the day of her admission. -- 2. According to an incident / accident report dated 06/22/11 at 2:15 p.m. (quoted as written): ""Resident was in bathroom in her room doing an unassisted ambulation. Resident went to sit on toilet & fell . Resident hit (L) (left) forehead on floor has hematoma there (symbol for 'no') C/O (complaint of) pain. (Symbol for 'no') further distress noted."" On Page 2 of the incident report, the results of the facility's investigation into this fall were as follows (quoted as written): ""(Symbol for 'no') further injuries. Bed locked in lowest position. Call light in reach."" A ""Fall Investigation Worksheet"" form, dated 06/22/11, identified the resident fell from a standing position, she was wearing socks but no shoes at the time of the fall, she was receiving narcotics and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. A ""Resident Fall Evaluation"" form was completed on 06/22/11, on which the assessor recorded ""Y"" for ""yes"" in response to the following questions: - ""fell in Last 30 Days?"" - ""Has there been a change in mobility?"" - ""Has there been a change in gait?"" - ""Does resident need assistance with bed mobility, transfer or ambulation?"" - ""Is the resident confused?"" - ""Has there been a change in mental status?"" - ""Does resident wear glasses?"" - ""Can the resident communicate their needs?"" (The assessor responded ""N"" for ""no"" to the question ""Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?"", although the resident continued to receive medications that affected blood pressure and the episodic care plan discussed below identified the need to monitor the resident's orthostatic blood pressure every shift.) On 06/22/11, an episodic care plan was developed as follows (quoted as written): - Problem - ""Fall /c (with) hematoma to (L) (left) forehead."" Goal - ""(Symbol for 'no') further falls."" Approaches - ""(1) Bed locked in lowest position. (2) Call bell in reach. (3) Room clutter free. (4) Notify MD of (symbol for 'changes')."" A second problem statement also dated 06/22/11 stated: - Problem - ""Fall /c hematoma."" Goal - ""(Symbol for 'no') further falls."" Approaches - ""(5) Orthostatic B/P (blood pressure) QS (every shift). (6) [MEDICATION NAME] 0.5 mg q (every) 4 hours. Hold if drowsy. (7) [MEDICATION NAME] 0.5 mg q 8 hours PRN (as needed)."" This episodic care plan did not take into account the information recorded on the ""Resident Fall Evaluation"" form, which noted the resident had exhibited a change in mental status and was now confused - two (2) [MEDICATION NAME] fall risk factors that had not been identified on the ""Resident Fall Evaluation"" form completed on 06/20/11. - Review of the resident's physician orders [REDACTED]. - 06/26/11 - ""Apply bed alarm to bed for residents safety and check for placement every shift R/T (related to) H/O (history of) Falls. - Every Shift Everyday"" - 06/26/11 - ""Apply chair alarm and check placement every shift for resident's safety R/T H/O Falls - Every Shift Everyday"" - 06/26/11 - ""Apply safety mats at bedside for resident's safety while in bed and check placement every shift, while in bed R/T H/O Falls - Every Shift Everyday"" -- 3. According to an incident / accident report dated 07/01/11 at 4:15 a.m. (quoted as written): ""Resident attempted to sit in a chair, missed the chair, and slid to floor landing on buttocks. Moves all extremities /s (without) difficulty."" This fall occurred at the nurses' station. A ""Fall Investigation Worksheet"" form, dated 07/01/11, identified the resident fell from a standing position when attempting to sit, she had an unsteady gait, she was wearing socks and shoes at the time of the fall, she was receiving antipsychotics, antianxiety medications, narcotics, and antihypertensives, and she was confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. - On 07/01/11, the comprehensive care plan was updated with the following problem, goal, and interventions (quoted as typed): - Problem - ""Potential for further decline in cognition related to [DIAGNOSES REDACTED]."" Goal - ""Respond to questions/ statement with appropriate verbalization and will know where she is and current month and year when ask at least 5 out of 7 days per week thru next review."" (Target date: 09/20/11) Interventions - ""Give one simple direction at a time and repeat it as necessary. Encourage participation in self-care within individual abilities. Encourage small group activities. Establish daily routine with resident. Explain each activity/ care procedure prior to beginning it. Provide reality orientation. Observe and report changes in cognitive status. Keep questions simple. Ensure access to clock/ calendar."" Additionally on 07/01/11, an episodic care plan was developed as follows (quoted as written): - Problem - ""Fall."" Goal - ""(Symbol for 'no') further falls through review."" (No review date was provided that would make this goal measurable.) Approaches - ""(1) Necessary items within reach at all times. (2) Call light within reach. (3) Bed alarm / chair alarm. (4) Floor matts. (5) Encourage resident to ask for assistance /c (with) all xfers (transfers)."" A form titled ""Multidisciplinary Screening Form"", dated 07/01/11 and completed by the physical therapist, found the following (quoted as written): ""4:15 am - 7/1/11 - patient was sitting in a chair missed the chair and fell pt (patient) is on caseload."" -- 4. A nursing note, dated 07/02/11 (with no time), stated (quoted as written): ""Resident keep getting up and turning off her alarms. Will not listen to reason. She keeps getting up and staggering around. Reported to charge nurse."" The next consecutive note (which was no in chronologic order when viewed with the rest of the nursing notes on other pages), was dated ""7/9/10/11 7p-7a"" and stated (quoted as written): ""Resident turns her alarms off and walks around the nurses desk and her room. She refuses help and says she can do it herself."" Additional entries in the nursing notes periodically noted Resident #206 was alert and oriented to person and place only, with episodes of confusion noted at times. On 07/06/11, the order for placement of floor mats beside the resident's bed was discontinued. -- 5. According to an incident / accident report dated 07/11/11 at 5:17 p.m. (quoted as written): ""Resident fell in dinning room. Chair alarm didn't alarm until resident was in floor. Resident fell on left side. C/O (complained of) left shoulder pain. 3cm S/T (skin tear) to left elbow."" A ""Fall Investigation Worksheet"" form, dated 07/11/11, identified the resident fell while engaging in unassisted ambulation from her wheelchair, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was alert. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", the person who completed this section (which was not signed or dated) wrote: ""Advise resident not to ambulate without help. Apply new alarm pad."" A nursing note, dated 07/11/11 at 1815 (6:15 p.m.), stated (quoted as written): ""Resident fell in dining room chair alarm was on but did not activate alarm til resident was on floor. She said she hit her head. C/O left shoulder pain 3 cm skin tar at elbow. ... Called Dr. (name) wants sent out for X-Rays ..."" A nursing note, dated 07/13/11 (with no time noted), stated (quoted as written): ""late entry for 7/11/11 Resident is noncompliant of chair alarm. Explain to resident the importance of chair alarm & resident is still non-compliant."" A nursing note, dated 07/11/11 at 2200 (10:00 p.m.), stated (quoted as written): ""Resident back from hospital ... Res dx of (illegible) fx (fracture) of the clavicle. N.O. (new order) for [MEDICATION NAME] q 6 hours PRN for pain #15. Report from hosp stated resident to be careful of falls. ..."" An episodic care plan was developed on 07/11/11 with the following (quoted as written): - Problem - ""Fall /c injury to (illegible)."" Goal - ""(1) Resident will have (symbol for 'no') more falls (illegible)."" Approach - ""(1) Resident to be instructed on call light to call for assist /c transfer to bathroom & other needs assist x 1 /c ambulation QS."" (This intervention identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's [MEDICAL CONDITION] and decline in cognition associated with the progression of the resident's [MEDICAL CONDITION].) A form titled ""Multidisciplinary Screening Form"", dated 07/12/11 and completed by the physical therapist, found the following (quoted as written): ""7/11/11 - pt (patient) fell - on caseload for balance, safety awareness due to poor judgment Working /c Daughter re: (regarding) inability to direct patient to safe behavior spoke /c them re: DC (discharge) placement since pt won't follow Directions."" -- 6. According to an incident / accident report dated 07/12/11 at 6:10 p.m. (quoted as written): ""CNA (certified nurse aide) escorted resident to room after dinner. CNA had to go help get other residents fr (from) dining room. Pt (patient) was in chair when CNA left room. Another CNA was passing by in hallway and heard a thump and quickly ran to room for help. The alarm was not going off when room was entered. Pt is known to turn off chair alarm. Found pt laying on (L) (left) side laceration above (L) eye brow & skin tear on top of (L) wrist & complaining of (L) hip pain. Resident sent out immediately."" This fall occurred in the resident's room. A ""Fall Investigation Worksheet"" form, dated 07/12/11, identified the resident fell from a stationary chair and that she was trying to transfer herself from chair to bathroom, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. The next consecutive nursing note following the resident's return from the hospital on [DATE], dated 07/12/11 at 1815 (6:15 p.m.), stated (quoted as written): ""Resident fell in room. Laceration on (L) side of head. C/O (L) hip pain. Called Dr. (name) ... Dr. (name) said send to ER (emergency room ) ... also has aprox 3cm skin tear to top of (L) wrist."" The next consecutive nursing note, dated 07/12/11 at 2315 (11:15 p.m.), stated (quoted as written): ""Resident back from (hospital) ... Resident alert. Steri-strip noted to laceration (L) side of head. (Symbol for 'no') new orders sent per Hosp. Dr. (name) called. N.O. for resident to be instructed to use call light for assist for transfer for bathroom or other needs et (and) assist of 1 for ambulation as (illegible) (checkmark) compliance QS (every shift). ..."" An episodic care plan was developed on 07/12/11 with the following (quoted as written): - Problem - ""Pt had fall in room."" Goal - ""Pt will free of falls for next evaluation."" Approach - ""(1) Encourage pt to use call light. (2) Encourage pt to shout out for help. (3) Call light within reach."" (Again, these interventions identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's [MEDICAL CONDITION] and decline in cognition associated with the progression of the resident's [MEDICAL CONDITION].) A form titled ""Multidisciplinary Screening Form"", dated 07/13/11 and completed by the physical therapist, found the following (quoted as written): ""7/12/11 - pt (patient) fell - on caseload for safety see previous fall screen 7/11/11 same issues as previously noted."" -- 7. According to an incident / accident report dated 07/18/11 at 12:30 p.m. (quoted as written): ""Resident stood up out of w/c (wheelchair). I redirected resident. While resident was sitting back down, w/c rolled back resident fell to floor on left side. Resident has c/o (complained of) pain (L) leg. N/O (new order) for x-rays obtain. Neuro's started."" This fall occurred in the dining room. A ""Fall Investigation Worksheet"" form, dated 07/18/11, identified the resident fell from a wheelchair while attempting unassisted ambulation, she had a malignant neoplasm of the brain and spinal cord, she was wearing socks and shoes at the time of the fall, she was receiving antianxiety medications, narcotics, and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. A form titled ""Multidisciplinary Screening Form"", dated 07/19/11 and completed by the physical therapist, found the following (quoted as written): ""7/18/11 - pt fell in DR (dining room) trying to get up out of chair. Antiroll (illegible) orders for wc (wheelchair) Patient on caseload being DC's (discharged ) - today Daughter aware working /c family for safety awareness."" After the resident sustained [REDACTED]. They continued to rely on the intervention of reminding the resident to use her call light for assistance. No new interventions by nursing or therapy staff were added between the falls on 07/11/11, 07/12/11, and 07/18/11. -- 8. Review of the facility's Fall Management Program (adopted January 2008; revised December 2010) found the following expectations in Section 1 (Fall Prevention) (quoted as typed): ""... A licensed nurse performs a head-to-toe evaluation of each new admission. When evaluating a resident who may be at risk for falling, the licensed nurse should consider the medical history, [DIAGNOSES REDACTED]. .. ""... After the head-to-toe assessment, the licensed nurse completes a Fall Evaluation on every new admission. This evaluation identifies both the [MEDICATION NAME] and extrinsic risk factors that apply to the particular resident. ""... Once the assessment and evaluation are completed and risk factors have been identified, the licensed nurse selects appropriate interventions. The Fall Evaluation Intervention tool is utilized to provide a standardized, quick, easy to use crosswalk that relates risk factors to suggested interventions. These practical intervention options can help the licensed nurse with the next task - developing a comprehensive individualized Care Plan. ... ""... Each week, the interdisciplinary team teams residents who are new admissions and residents who have fallen in the past 90 days during the C.A.R.E. meeting. The knowledge and expertise that is shared at these meetings enhances the quality of care provided to residents. During the C.A.R.E. meeting, care strategies are evaluated and the care plan is adjusted, as necessary. ..."" - The following expectations were found in Section 2 (Fall Management) (quoted as typed): ""... A specific procedure is followed to report and investigate falls. This ensures that the resident receives appropriate care after a fall, that an investigation is begun, and that the resident's care plan is adjusted, as needed. ... ""... After the resident has been cared for (when a resident falls), the licensed nurse: ""1. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. Note: Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress Notes during each shift for the next 24 hours, and daily for the next 48 hours, noting any changes in condition - a total of 72 hours) ""2. Completes a Fall Evaluation to determine if there have been any changes in resident condition and to identify interventions that may help in preventing future falls ""3. Completes an incident and accident report ... including a fall investigation ""4. Updates the Care Plan with the identified interventions ""5. Updates the Nursing Assistant Care Card with any new procedures ""6. Completes the 24-Hour Report, to alert following shifts to the fall, as well as Care Plan updates ""7. Residents are followed via the 24 Hour Report x 72 hours ..."" -- 9. When interviewed on the afternoon of 08/04/11, Employee #9 (the minimum data set manager) reported the facility wanted to initiate a program that would date the alarms and alert staff as to when these alarms / batteries needed to be changed. An interview with the registered nurse (RN) consultant (Employee #28A), on 08/04/11, revealed the facility had not conducted the C.A.R.E. meetings as stated in the Fall Management Program provided by the facility. Employee #28A said the facility had not conducted these meetings due to not having a director of nursing. However, the facility utilized an interim director of nursing (DON - Employee #27A) during the time period these falls occurred. -- 10. On 08/04/11 at approximately 3:00 p.m., Employee #1A (the therapy program manager) said the resident experienced a lot of agitation while at the facility. Her functioning abilities fluctuated. She said this made the resident's abilities difficult to judge. She said the facility did not try a Rock-N-Go chair with this resident, but this may have been beneficial to her. On 08/04/11 at approximately 3:15 p.m., Employee #9 said the resident often tried to get up from her chair when her family would leave the facility. The facility did not incorporate into the care plan and/or develop approaches to promote resident safety based on this information. -- f) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED]."". Resident #214's interim care plan, which was initiated upon her admission on 07/19/11, did not address the resident's risk for falls, even though staff was aware that the resident had sustained one (1) or more falls prior to her admission. - According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or whether she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound VAC to measure and apply a new dressing. The wound VAC dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. - On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her Medication Administration Record [REDACTED].) Review of the ""Resident Fall Evaluation"" completed on 07/23/11 revealed the assessor wrote ""N"" for ""no"" in response to the following questions: - ""Has resident had changes in their medication?"" - ""Is resident on any new medications?"" - ""Was resident experiencing pain prior to the fall?"" An episodic care plan, dated 07/23/11, contained the following problem, goal, and approaches (quoted as written): Problem - ""Fall r/t (related to) poor safety awareness."" Goal - ""No further falls."" Approaches - ""(1) Call bell in reach. (2) Visualize resident frequently. (3) Safety mats to bedside when in bed. (3) Pressure alarm to bed to alert staff to unassisted transfers."" On 07/24/11, nursing notes stated: ""S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. -- 2. Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. - On 07/27/11, the resident's medical record was reviewed for documentation of the factors surrounding this resident's falls. There was no contemporaneous entry in the nursing notes to correspond with the fall on 07/26/11, and there was no evidence to reflect staff conducted a physical assessment of the resident and no evidence to reflect staff conducted an investigation to identify possible [MEDICATION NAME] and/or extrinsic factors that may have contributed to this fall. A nursing note, dated ""07/24/11"", stated Resident #214 had a fall on 07/26/11. This was brought to the attention of Employee #28A, who stated this note was probably dated incorrectly, because it was written after a note dated 07/25/11. She said this note must have been intended for 07/26/11, as the next consecutive note, dated 07/27/11, stated the resident had no further falls. Employee #28A verified there was no note in the medical record to describe the details of the fall that had occurred on 07/26/11. - The facility's incident / accident reports were reviewed, and no report was found for Resident #214's fall on 07/26/11. Additionally, ""Resident Fall Evaluation"" and ""Fall Investigation Worksheet"" forms were not completed following this fall on 07/26/11. - Subsequent review of the resident's care plan found it was not reviewed / revised after the fall on 07/26/11 as required by the facility's Fall Management Plan, to include new or different interventions to prevent future falls from occurring. .",2014-12-01
10696,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,309,E,1,0,UBFP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure (1) of thirteen (13) sampled residents, whose physician gave orders on 10/11/11 for intravenous (IV) antibiotic therapy ([MEDICATION NAME] 1 Gm daily for seven (7) days) to treat a urinary tract infection [MEDICAL CONDITION], received the first dose of [MEDICATION NAME] as scheduled on 10/11/11 due to lack of availability of the medication from the pharmacy. Resident identifier: #16. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: ""She was treated with intravenous [MEDICATION NAME]. Urine culture grew proteus mirabilis, sensitive to [MEDICATION NAME]."" On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]."" A nursing note dated 10/11/11 at 11:30 a.m. stated, ""Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) [MEDICATION NAME] to 1 grm (gram) IV q (every) 24 hr x 7 days, [MEDICATION NAME] 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound contact precautions maintained QS (every shift)."" - Review of Resident #16's medication administration record (MAR), with the registered nurse (RN) unit manager for the East wing on the afternoon of 10/26/11, revealed an ""X"" where a nurse was to have initialed the MAR to indicate the first dose of IV [MEDICATION NAME] had been administered on 10/11/11. The East wing unit manager said the resident had a med port (IV access) and that all the initials on the other days of administration were from RNs. She commented that an RN would have had to administer all the IV doses. She looked at the ""X"" and said this meant the [MEDICATION NAME] was not administered on that date. She said she did not know why it was not given. - On the afternoon of 10/27/11, the director of nursing (DON - Employee #12) also reviewed the resident's MAR and said she, too, did not know why the dose of IV [MEDICATION NAME] scheduled for 10/11/11 was not given. In a subsequent interview on 10/27/11 at approximately 1:50 p.m., the DON confirmed Resident #16 had arrived at the facility on 10/10/11 and should have received a dose of [MEDICATION NAME] on 10/11/11 but did not. According to the DON, the facility did not have this medication available for administration on 10/11/11. .",2014-12-01
10697,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,323,G,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to ensure three (3) of forty-five (45) Stage II sample residents received adequate supervision and assistance devices to prevent avoidable accidents, resulting in actual harm to one (1) resident. Additionally, staff failed to follow the facility's Fall Management Program with respect to documentation, assessment, care planning, and post-fall evaluations. Resident #206 was admitted on [DATE] and sustained five (5) falls between 06/22/11 and 07/18/11; two (2) of the falls required transfer to the hospital, one (1) of which resulted in a fractured clavicle. The resident had diminished cognitive ability due to malignant brain cancer. The interdisciplinary team (IDT) did not develop new interventions that were appropriate for a resident with diminished cognitive ability, relying upon the resident to exercise good judgment to promote her own safety (e.g., instructing the resident to ask for staff assistance with transfers). The facility kept the same interventions in place after the resident continued to sustain falls with serious injuries. Resident #214 sustained a fall on 07/26/11, and staff did not complete a physical assessment of the resident after the fall, nor did they follow the other post-fall action steps outline in the facility's policy. Resident #37 had a care plan intervention for his bed to be in the lowest position due to falls. Observation revealed this intervention was not implemented as planned. Resident identifiers: #206, #214, and #37. Facility census: 105. Findings include: a) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled ""Determination of Capacity / Incapacity / Designated Surrogate"", which was not signed or dated. The person completing this form checked Item C ""_______ demonstrates INCAPACITY to make medical decisions"" and designated the resident's daughter to serve as health care surrogate. Upon the resident's admission to the facility, no physician's determination of capacity was made. (A form titled ""Physician's Determination of Capacity"" was found in Resident #206's medical record; it was signed by the physician and dated 07/06/11, but the form was otherwise blank - with no indication was to whether the resident did or did not possess the capacity to understand and make her own health care decisions.) On the day of her admission (06/20/11), a ""Resident Fall Evaluation"" form was completed. The assessor recorded ""Y"" for ""yes"" in response to the following questions: - ""fell in Last 30 Days?"" - ""Has there been a change in mobility?"" - ""Has there been a change in gait?"" - ""Does resident need assistance with bed mobility, transfer or ambulation?"" - ""Has resident had changes in their medication?"" - ""Is resident on any new medications?"" - ""Does resident wear glasses?"" - ""Can the resident communicate their needs?"" - ""Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?"" - Review of the resident's physician orders [REDACTED]. - 06/20/11 - ""haldol 0.5mg tab By mouth (oral) - PRN PRN: Give Q 8 hours prn - psychosis"" - 06/21/11 - ""Ativan (Lorazepam) 1 MG Tablet By mouth (Oral) - Every four hours Everyday: Hold ativan if drowsy - Anxiety"" - Episodic care plans, dated 06/21/11, included the following problems, goals, and approaches (quoted as written): - Problem - ""(Arrow pointing down) ADL (activities of daily living), weakness, (arrow pointing down) activity tolerance, (arrow pointing down) balance, (arrow pointing down) mobility."" Goal - ""Max I (maximum independence) /c (with) ADL for safe D/C (discharge) to appropriate level of care."" Approaches - ""See HCFA 700 for POC (plan of care)."" (This care plan was written by the occupational therapist.) - Problem - ""(Arrow pointing down) cognitive skills."" Goals - ""(Arrow pointing up) cognitive skills."" Approaches - ""See HCFA 700 for POC."" (This care plan was written by the speech-language pathologist.) - Problem - ""(Arrow pointing down) bed mob (mobility), (arrow pointing down) transfer, (arrow pointing down) amb (ambulation)."" Goal - ""Safe / I to return to Home."" Approaches - ""See HCFA 700."" (This care plan was written by the physical therapist.) No care plan was developed upon admission to address the resident's risk for falls, which would have been appropriate given the intrinsic risk factors for falling that had been identified on the ""Resident Fall Evaluation"" form completed on the day of her admission. -- 2. According to an incident / accident report dated 06/22/11 at 2:15 p.m. (quoted as written): ""Resident was in bathroom in her room doing an unassisted ambulation. Resident went to sit on toilet & fell . Resident hit (L) (left) forehead on floor has hematoma there (symbol for 'no') C/O (complaint of) pain. (Symbol for 'no') further distress noted."" On Page 2 of the incident report, the results of the facility's investigation into this fall were as follows (quoted as written): ""(Symbol for 'no') further injuries. Bed locked in lowest position. Call light in reach."" A ""Fall Investigation Worksheet"" form, dated 06/22/11, identified the resident fell from a standing position, she was wearing socks but no shoes at the time of the fall, she was receiving narcotics and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. A ""Resident Fall Evaluation"" form was completed on 06/22/11, on which the assessor recorded ""Y"" for ""yes"" in response to the following questions: - ""fell in Last 30 Days?"" - ""Has there been a change in mobility?"" - ""Has there been a change in gait?"" - ""Does resident need assistance with bed mobility, transfer or ambulation?"" - ""Is the resident confused?"" - ""Has there been a change in mental status?"" - ""Does resident wear glasses?"" - ""Can the resident communicate their needs?"" (The assessor responded ""N"" for ""no"" to the question ""Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?"", although the resident continued to receive medications that affected blood pressure and the episodic care plan discussed below identified the need to monitor the resident's orthostatic blood pressure every shift.) On 06/22/11, an episodic care plan was developed as follows (quoted as written): - Problem - ""Fall /c (with) hematoma to (L) (left) forehead."" Goal - ""(Symbol for 'no') further falls."" Approaches - ""(1) Bed locked in lowest position. (2) Call bell in reach. (3) Room clutter free. (4) Notify MD of (symbol for 'changes')."" A second problem statement also dated 06/22/11 stated: - Problem - ""Fall /c hematoma."" Goal - ""(Symbol for 'no') further falls."" Approaches - ""(5) Orthostatic B/P (blood pressure) QS (every shift). (6) Ativan 0.5 mg q (every) 4 hours. Hold if drowsy. (7) Haldol 0.5 mg q 8 hours PRN (as needed)."" This episodic care plan did not take into account the information recorded on the ""Resident Fall Evaluation"" form, which noted the resident had exhibited a change in mental status and was now confused - two (2) intrinsic fall risk factors that had not been identified on the ""Resident Fall Evaluation"" form completed on 06/20/11. - Review of the resident's physician orders [REDACTED]. - 06/26/11 - ""Apply bed alarm to bed for residents safety and check for placement every shift R/T (related to) H/O (history of) Falls. - Every Shift Everyday"" - 06/26/11 - ""Apply chair alarm and check placement every shift for resident's safety R/T H/O Falls - Every Shift Everyday"" - 06/26/11 - ""Apply safety mats at bedside for resident's safety while in bed and check placement every shift, while in bed R/T H/O Falls - Every Shift Everyday"" -- 3. According to an incident / accident report dated 07/01/11 at 4:15 a.m. (quoted as written): ""Resident attempted to sit in a chair, missed the chair, and slid to floor landing on buttocks. Moves all extremities /s (without) difficulty."" This fall occurred at the nurses' station. A ""Fall Investigation Worksheet"" form, dated 07/01/11, identified the resident fell from a standing position when attempting to sit, she had an unsteady gait, she was wearing socks and shoes at the time of the fall, she was receiving antipsychotics, antianxiety medications, narcotics, and antihypertensives, and she was confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. No ""Resident Fall Evaluation"" form was completed following this fall. - On 07/01/11, the comprehensive care plan was updated with the following problem, goal, and interventions (quoted as typed): - Problem - ""Potential for further decline in cognition related to [DIAGNOSES REDACTED]."" Goal - ""Respond to questions/ statement with appropriate verbalization and will know where she is and current month and year when ask at least 5 out of 7 days per week thru next review."" (Target date: 09/20/11) Interventions - ""Give one simple direction at a time and repeat it as necessary. Encourage participation in self-care within individual abilities. Encourage small group activities. Establish daily routine with resident. Explain each activity/ care procedure prior to beginning it. Provide reality orientation. Observe and report changes in cognitive status. Keep questions simple. Ensure access to clock/ calendar."" Additionally on 07/01/11, an episodic care plan was developed as follows (quoted as written): - Problem - ""Fall."" Goal - ""(Symbol for 'no') further falls through review."" (No review date was provided that would make this goal measurable.) Approaches - ""(1) Necessary items within reach at all times. (2) Call light within reach. (3) Bed alarm / chair alarm. (4) Floor matts. (5) Encourage resident to ask for assistance /c (with) all xfers (transfers)."" A form titled ""Multidisciplinary Screening Form"", dated 07/01/11 and completed by the physical therapist, found the following (quoted as written): ""4:15 am - 7/1/11 - patient was sitting in a chair missed the chair and fell pt (patient) is on caseload."" -- 4. A nursing note, dated 07/02/11 (with no time), stated (quoted as written): ""Resident keep getting up and turning off her alarms. Will not listen to reason. She keeps getting up and staggering around. Reported to charge nurse."" The next consecutive note (which was no in chronologic order when viewed with the rest of the nursing notes on other pages), was dated ""7/9/10/11 7p-7a"" and stated (quoted as written): ""Resident turns her alarms off and walks around the nurses desk and her room. She refuses help and says she can do it herself."" Additional entries in the nursing notes periodically noted Resident #206 was alert and oriented to person and place only, with episodes of confusion noted at times. On 07/06/11, the order for placement of floor mats beside the resident's bed was discontinued. -- 5. According to an incident / accident report dated 07/11/11 at 5:17 p.m. (quoted as written): ""Resident fell in dinning room. Chair alarm didn't alarm until resident was in floor. Resident fell on left side. C/O (complained of) left shoulder pain. 3cm S/T (skin tear) to left elbow."" A ""Fall Investigation Worksheet"" form, dated 07/11/11, identified the resident fell while engaging in unassisted ambulation from her wheelchair, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was alert. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", the person who completed this section (which was not signed or dated) wrote: ""Advise resident not to ambulate without help. Apply new alarm pad."" No ""Resident Fall Evaluation"" form was completed following this fall. A nursing note, dated 07/11/11 at 1815 (6:15 p.m.), stated (quoted as written): ""Resident fell in dining room chair alarm was on but did not activate alarm til resident was on floor. She said she hit her head. C/O left shoulder pain 3 cm skin tar at elbow. ... Called Dr. (name) wants sent out for X-Rays ..."" A nursing note, dated 07/13/11 (with no time noted), stated (quoted as written): ""late entry for 7/11/11 Resident is noncompliant of chair alarm. Explain to resident the importance of chair alarm & resident is still non-compliant."" A nursing note, dated 07/11/11 at 2200 (10:00 p.m.), stated (quoted as written): ""Resident back from hospital ... Res dx of (illegible) fx (fracture) of the clavicle. N.O. (new order) for Vicoprofen q 6 hours PRN for pain #15. Report from hosp stated resident to be careful of falls. ..."" An episodic care plan was developed on 07/11/11 with the following (quoted as written): - Problem - ""Fall /c injury to (illegible)."" Goal - ""(1) Resident will have (symbol for 'no') more falls (illegible)."" Approach - ""(1) Resident to be instructed on call light to call for assist /c transfer to bathroom & other needs assist x 1 /c ambulation QS."" (This intervention identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's psychosis and decline in cognition associated with the progression of the resident's brain cancer.) A form titled ""Multidisciplinary Screening Form"", dated 07/12/11 and completed by the physical therapist, found the following (quoted as written): ""7/11/11 - pt (patient) fell - on caseload for balance, safety awareness due to poor judgment Working /c Daughter re: (regarding) inability to direct patient to safe behavior spoke /c them re: DC (discharge) placement since pt won't follow Directions."" -- 6. According to an incident / accident report dated 07/12/11 at 6:10 p.m. (quoted as written): ""CNA (certified nurse aide) escorted resident to room after dinner. CNA had to go help get other residents fr (from) dining room. Pt (patient) was in chair when CNA left room. Another CNA was passing by in hallway and heard a thump and quickly ran to room for help. The alarm was not going off when room was entered. Pt is known to turn off chair alarm. Found pt laying on (L) (left) side laceration above (L) eye brow & skin tear on top of (L) wrist & complaining of (L) hip pain. Resident sent out immediately."" This fall occurred in the resident's room. A ""Fall Investigation Worksheet"" form, dated 07/12/11, identified the resident fell from a stationary chair and that she was trying to transfer herself from chair to bathroom, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. No ""Resident Fall Evaluation"" form was completed following this fall. The next consecutive nursing note following the resident's return from the hospital on [DATE], dated 07/12/11 at 1815 (6:15 p.m.), stated (quoted as written): ""Resident fell in room. Laceration on (L) side of head. C/O (L) hip pain. Called Dr. (name) ... Dr. (name) said send to ER (emergency room ) ... also has aprox 3cm skin tear to top of (L) wrist."" The next consecutive nursing note, dated 07/12/11 at 2315 (11:15 p.m.), stated (quoted as written): ""Resident back from (hospital) ... Resident alert. Steri-strip noted to laceration (L) side of head. (Symbol for 'no') new orders sent per Hosp. Dr. (name) called. N.O. for resident to be instructed to use call light for assist for transfer for bathroom or other needs et (and) assist of 1 for ambulation as (illegible) (checkmark) compliance QS (every shift). ..."" An episodic care plan was developed on 07/12/11 with the following (quoted as written): - Problem - ""Pt had fall in room."" Goal - ""Pt will free of falls for next evaluation."" Approach - ""(1) Encourage pt to use call light. (2) Encourage pt to shout out for help. (3) Call light within reach."" (Again, these interventions identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's psychosis and decline in cognition associated with the progression of the resident's brain cancer.) A form titled ""Multidisciplinary Screening Form"", dated 07/13/11 and completed by the physical therapist, found the following (quoted as written): ""7/12/11 - pt (patient) fell - on caseload for safety see previous fall screen 7/11/11 same issues as previously noted."" -- 7. According to an incident / accident report dated 07/18/11 at 12:30 p.m. (quoted as written): ""Resident stood up out of w/c (wheelchair). I redirected resident. While resident was sitting back down, w/c rolled back resident fell to floor on left side. Resident has c/o (complained of) pain (L) leg. N/O (new order) for x-rays obtain. Neuro's started."" This fall occurred in the dining room. A ""Fall Investigation Worksheet"" form, dated 07/18/11, identified the resident fell from a wheelchair while attempting unassisted ambulation, she had a malignant neoplasm of the brain and spinal cord, she was wearing socks and shoes at the time of the fall, she was receiving antianxiety medications, narcotics, and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record ""Recommendations to prevent further falls (document interventions below and on the Care Plan)"", this section of the form was left blank. No ""Resident Fall Evaluation"" form was completed following this fall. A form titled ""Multidisciplinary Screening Form"", dated 07/19/11 and completed by the physical therapist, found the following (quoted as written): ""7/18/11 - pt fell in DR (dining room) trying to get up out of chair. Antiroll (illegible) orders for wc (wheelchair) Patient on caseload being DC's (discharged ) - today Daughter aware working /c family for safety awareness."" After the resident sustained [REDACTED]. They continued to rely on the intervention of reminding the resident to use her call light for assistance. No new interventions by nursing or therapy staff were added between the falls on 07/11/11, 07/12/11, and 07/18/11. -- 8. Review of the facility's Fall Management Program (adopted January 2008; revised December 2010) found the following expectations in Section 1 (Fall Prevention) (quoted as typed): ""... A licensed nurse performs a head-to-toe evaluation of each new admission. When evaluating a resident who may be at risk for falling, the licensed nurse should consider the medical history, [DIAGNOSES REDACTED]. .. ""... After the head-to-toe assessment, the licensed nurse completes a Fall Evaluation on every new admission. This evaluation identifies both the intrinsic and extrinsic risk factors that apply to the particular resident. ""... Once the assessment and evaluation are completed and risk factors have been identified, the licensed nurse selects appropriate interventions. The Fall Evaluation Intervention tool is utilized to provide a standardized, quick, easy to use crosswalk that relates risk factors to suggested interventions. These practical intervention options can help the licensed nurse with the next task - developing a comprehensive individualized Care Plan. ... ""... Each week, the interdisciplinary team teams residents who are new admissions and residents who have fallen in the past 90 days during the C.A.R.E. meeting. The knowledge and expertise that is shared at these meetings enhances the quality of care provided to residents. During the C.A.R.E. meeting, care strategies are evaluated and the care plan is adjusted, as necessary. ..."" - The following expectations were found in Section 2 (Fall Management) (quoted as typed): ""... A specific procedure is followed to report and investigate falls. This ensures that the resident receives appropriate care after a fall, that an investigation is begun, and that the resident's care plan is adjusted, as needed. ... ""... After the resident has been cared for (when a resident falls), the licensed nurse: ""1. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. Note: Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress Notes during each shift for the next 24 hours, and daily for the next 48 hours, noting any changes in condition - a total of 72 hours) ""2. Completes a Fall Evaluation to determine if there have been any changes in resident condition and to identify interventions that may help in preventing future falls ""3. Completes an incident and accident report ... including a fall investigation ""4. Updates the Care Plan with the identified interventions ""5. Updates the Nursing Assistant Care Card with any new procedures ""6. Completes the 24-Hour Report, to alert following shifts to the fall, as well as Care Plan updates ""7. Residents are followed via the 24 Hour Report x 72 hours ..."" - The following expectations were found in Section 3 (Performance Improvement in Fall Management) (quoted as typed): ""... Daily: The center interdisciplinary team reviews the 24-Hour Report at morning meetings and discusses residents who have fallen. ""Weekly: The center team discusses residents during the C.A.R.E. meeting to determine the effectiveness of the Care Plan. ""Monthly: The Safety Committee receives information on any falls resulting from environmental (extrinsic) factors, investigates, and reports its findings to the Quality Assurance Committee. The Performance Improvement Committee reviews fall to determine if there are trends in the center that require action. ..."" -- 9. When interviewed on the afternoon of 08/04/11, Employee #9 (the minimum data set manager) reported the facility wanted to initiate a program that would date the alarms and alert staff as to when these alarms / batteries needed to be changed. An interview with the registered nurse (RN) consultant (Employee #28A), on 08/04/11, revealed the facility had not conducted the C.A.R.E. meetings as stated in the Fall Management Program provided by the facility. Employee #28A said the facility had not conducted these meetings due to not having a director of nursing. However, the facility utilized an interim director of nursing (DON - Employee #27A) during the time period these falls occurred. -- 10. On 08/04/11 at approximately 3:00 p.m., Employee #1A (the therapy program manager) said the resident experienced a lot of agitation while at the facility. Her functioning abilities fluctuated. She said this made the resident's abilities difficult to judge. She said the facility did not try a Rock-N-Go chair with this resident, but this may have been beneficial to her. On 08/04/11 at approximately 3:15 p.m., Employee #9 said the resident often tried to get up from her chair when her family would leave the facility. The facility did not incorporate into the care plan and/or develop approaches to promote resident safety based on this information. -- b) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED]."". Resident #214's interim care plan, which was initiated upon her admission on 07/19/11, did not address the resident's risk for falls, even though staff was aware that the resident had sustained one (1) or more falls prior to her admission. - According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or whether she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (vac) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound vac to measure and apply a new dressing. The wound vac dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on Diflucan (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for Ativan 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. - On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her medication administration record (MAR), Resident #214 received her first dose of Ativan at 10:00 a.m. on 07/23/11.) Review of the ""Resident Fall Evaluation"" completed on 07/23/11 revealed the assessor wrote ""N"" for ""no"" in response to the following questions: - ""Has resident had changes in their medication?"" - ""Is resident on any new medications?"" - ""Was resident experiencing pain prior to the fall?"" An episodic care plan, dated 07/23/11, contained the following problem, goal, and approaches (quoted as written): Problem - ""Fall r/t (related to) poor safety awareness."" Goal - ""No further falls."" Approaches - ""(1) Call bell in reach. (2) Visualize resident frequently. (3) Safety mats to bedside when in bed. (3) Pressure alarm to bed to alert staff to unassisted transfers."" On 07/24/11, nursing notes stated: ""S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. -- 2. Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. - On 07/27/11, the resident's medical record was reviewed for documentation of the factors surrounding this resident's falls. There was no contemporaneous entry in the nursing notes to correspond with the fall on 07/26/11, and there was no evidence to reflect staff conducted a physical assessment of the resident and no evidence to reflect staff conducted an investigation to identify possible intrinsic and/or extrinsic factors that may have contributed to this fall. A nursing note, dated ""07/24/11"", stated Resident #214 had a fall on 07/26/11. This was brought to the attention of Employee #28A, who stated this note was probably dated incorrectly, because it was written after a note dated 07/25/11. She said this note must have been intended for 07/26/11, as the next consecutive note, dated 07/27/11, stated the resident had no further falls. Employee #28A verified there was no note in the medical record to describe the details of the fall that had occurred on 07/26/11. - The facility's incident / accident reports were reviewed, and no report was found for Resident #214's fall on 07/26/11. Additionally, ""Resident Fall Evaluation"" and ""Fall Investigation Worksheet"" forms were not completed following this fall on 07/26/11. - Subsequent review of the resident's care plan found it was not reviewed / revised after the fall on 07/26/11 as required by the facility's Fall Management Plan, to include new or different interventions to prevent future falls from occurring. . Employee #28A was questioned again on 08/03/11 at 10:00 a.m. about the fall on 07/26/11. She did not provide evidence to reflect the resident had been thoroughly assessed after the fall or that the circumstance of the fall had been thoroughly investigated, as there was no incident / accident report, no ""Resident Fall Investigation"" form, no ""Fall Investigation Worksheet"" form, and no details about the fall recorded in the nursing notes. - The facility's Fall Management Program was reviewed, and on 08/03/11 at 2:00 p.m., Employee #28A was questioned further about follow-up actions taken by staff after the fall on 07/26/11. Employee #28A did not provide evidence that all applicable post-fall actions were taken as required by the Fall Management Program (as outlined above in Item #8 related to Resident #206). -- 3. Further record review for this resident found the Care Area Assessment (CAA) notes did not provide an additional assessment for the care areas that were triggered by the resident's most recent comprehensive MDS. The admission + Medicare 14-Day MDS, with an ARD of 07/31/11, indicated in Section C that Resident #214 had severely impaired cognition (Brief Interview for Mental Status score of ""4"") with impaired short-term recall. In Section J1700, the assessor recorded that Resident #214 had fallen in the month prior to ARD date and before the resident's admission to this facility. Documentation in Section V of the MDS indicated the care area of ""falls"" triggered and would be addressed in the care plan. This documentation also identified the location and date of the CAA information as ""CAA WS (worksheet) dated 8/1/11"". The CAA worksheet, dated 08/01/11, for the area of falls was reviewed. The CAA notes, dated 08/01/11, listed her medications, stated that she fell at home prior to coming to the facility, that she had a bed alarm to her bed and a high low bed with safety mats at bedside due to her poor safety awareness, and that she was unable to determine the edge of the bed. There was no information contained in the CAA notes to identify that this resident had fallen twice since her admission to the facility; both falls occurred prior to 08/01/11. The worksheet then provided a place to record an analysis of the findings; this analysis consisted of a paragraph restating the same information. There was no evidence of an in depth analysis of the find",2014-12-01
10698,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,329,G,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and review interview, the facility failed to ensure the medication regimens for two (2) of forty-five (45) Stage II sample residents were free from unnecessary drugs. One (1) resident (#214) received medications to treat anxiety and [MEDICAL CONDITION] when the resident displayed signs / symptoms of pain, and she was not prescribed any medications to treat pain; this resulted in actual harm (e.g., untreated pain). Another resident (#159) received a medication without adequate indications for its use. Resident identifiers: #159 and #214. Facility census: 105. Findings include: a) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or if she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident . A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. In Section 13.1a (integumentary / feet) of the admission nursing assessment, the assessor failed to mark a response to the following question: ""Is there pain associated with the wound/skin condition?"" - This section of the assessment was left blank. In Section 14.0 of the nursing admission assessment, the assessor responded as follows: - ""At anytime during the last five (5) days has the resident: Been on a scheduled pain medication regimen?"" = No - ""Been on a PRN (as needed) pain medication?"" = No - ""Had pain or hurting?"" = Yes (There was no follow-up documentation on the assessment to describe the pain or hurting the resident was experiencing.) -- 2. On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound VAC to measure and apply a new dressing. The wound VAC dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). On 07/20/11 at 5:00 p.m., a nursing note recorded the resident did not display any combativeness or other behaviors. On 07/21/11, the nursing notes stated that she did not display any behaviors on that day either. According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. on that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her Medication Administration Record [REDACTED].) On 07/24/11, nursing notes stated: ""S/p (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. A nursing note, on 07/25/11, recorded receipt of new orders for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 25 mg BID (twice daily) for [MEDICAL CONDITION]. There was no documentation to reflect the resident was exhibiting signs or symptoms of [MEDICAL CONDITION], nor was there evidence to reflect staff had assessed the resident for pain. - Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. On 07/27/11, the resident's medical record was reviewed to review the factors surrounding this resident's falls. There was no evidence that this fall had been recorded in the nursing notes, and there was no evidence that staff had conducted an investigation in an effort to identify internal and/or external factors that contributed to this fall. The incident / accident reports were reviewed for this time frame, and no report was found for the fall that occurred on 07/26/11. - On 07/28/11, a weekly nursing note stated: ""... she rips off wound vac, combative, curses staff, she is currently receiving [MEDICATION NAME] 25 mg BID. ..."" There was no evidence in the weekly interdisciplinary team (IDT) meeting note that pain was considered or ruled out as a reason for this resident's behaviors and pulling out her wound VAC. - Review of the resident's physician orders [REDACTED]. - The admission + Medicare 14-Day MDS, with an ARD of 07/31/11, indicated in Section C that Resident #214 had severely impaired cognition (Brief Interview for Mental Status score of ""4"") with impaired short-term recall. - During observations of this resident on 08/03/11 from 10:00 a.m. to 11:30 a.m., she was noted to be sleeping the entire time. Her lunch tray was provided to her, and at 1:15 p.m., this surveyor approached the resident. She was very lethargic, dozing off while she was eating. When interviewed by the surveyor about her meal, she reported she just wasn't very hungry. (Although ordered on [DATE], according to the MAR indicated [REDACTED].) Observation found the resident wrinkling her forehead and nose and grimacing. When asked if she was having pain, she stated ""yes"". When asked to describe her pain, she stated, ""A deep pain that is real deep and sharp shooting down my leg and into my foot."" When asked what treatment she received for pain, and she stated, ""It is all right. I do not need any more pills. I take too many now."" - At 1:30 p.m. on 08/03/11, two registered nurses (RNs - Employees #9 and #28A) were asked by this surveyor to assess this resident for pain. Employee #28A asked the resident if she was hurting anywhere, and the resident stated, ""Yes. My leg hurts from here to here."" (As she spoke, the resident pointed to the area surrounding the wound VAC on her left lower leg.) The RN asked her if she wanted some pain medication, and she said, ""No. I don't think I need it."" - On 08/03/11, the nurse practitioner (Employee #29A) wrote a note to follow-up with the wound center as soon as possible if not already seen, and to obtain a report from the wound center if she has already been seen. Employee #29A also wrote an order for [REDACTED]."" - On 08/09/11 at 9:30 a.m., Employee #43 (a licensed practical nurse - LPN) was observed performing a treatment to Resident #214's leg. Throughout the procedure, the resident winced and gritted her teeth. At times, she covered her mouth with her sheet, and at other times, she covered her face with both hands, whimpering all the while. She repeated ""golly, golly"" time and time again. At one point, she asked the nurse to quit for a while and let her relax. It was apparent that this resident was in extreme pain, and this was confirmed by Employees #43 and #29A, who was also present at that time. Employee #29A said she would order something stronger for the resident. The treatment was stopped, and they said they were going to let the medication work before they finished the treatment. At 10:05 a.m., they administered [MEDICATION NAME] to the resident. - It was evident this resident was experiencing pain, and this untreated pain could have been the cause of her behaviors. There was no evidence that pain was considered as a causal or contributing factor prior to medicating the resident with antianxiety and antipsychotic medications for behaviors. There was inadequate monitoring of the resident's behaviors for the months of July and August 2011. No behavior monitoring sheet was found for July 2011. The behavior monitoring sheet for August 2011 indicated staff was to monitor her for the behavior of ""fighting"", and documentation on this sheet month-to date indicated she had no episodes of fighting. Additionally, no non-pharmacologic interventions were initiated in an attempt to reduce these behaviors prior to administering antianxiety and/or antipsychotic medications. During an interview with Employee #28A, she was made aware that there was no behavior sheet for July 2011 (when the antipsychotic and antianxiety medications were ordered and administered) and that no documentation was found to justify the use of either the antianxiety medication (e.g., evidence of increased anxiety) or the antipsychotic medications. There was also no evidence that the risks and benefits had been considered before using these medications. There was also no evidence that the facility had considered pain as a possible cause of the resident's combativeness (as she had exhibited combativeness when her wound care was done), nor was there any evidence that the facility considered the time of day that wound care had been done (at 4:00 a.m. - during hours of sleep) as a factor in the behaviors. The resident also suffered two (2) falls after these medications were initiated. The antianxiety and antipsychotic medications were administered without adequate indications for their use, without adequate monitoring, and in the presence of adverse effects (lethargy and falls), and the resident's pain (which was not identified as a possible underlying cause of her behaviors) was left untreated. -- b) Resident #159 On 08/09/11 at approximately 10:25 a.m., medical record review for Resident #159 revealed she received the medication [MEDICATION NAME] 1 mg po (by mouth) twice a day everyday for [MEDICAL CONDITION] since 08/18/10. Further medical record review found the resident did not have an active [DIAGNOSES REDACTED]. Interviews with Employee #27A (the director of nursing - DON) and Employee #28A (an RN consultant) revealed no supporting [DIAGNOSES REDACTED]. .",2014-12-01
10699,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,425,E,1,0,UBFP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an intravenous (IV) antibiotic was available for administration as ordered for (1) of thirteen (13) sampled residents (#16), whose physician gave orders on 10/11/11 for IV Rocephin 1 Gm daily for seven (7) days to treat a urinary tract infection (UTI). Additionally, staff failed to obtain from the facility's emergency drug box and administer a dose of Lovenox to Resident #59 when that medication was not available from the pharmacy. Resident identifiers: #16 and #59. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: ""She was treated with intravenous Rocephin. Urine culture grew proteus mirabilis, sensitive to Rocephin."" On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]."" A nursing note dated 10/11/11 at 11:30 a.m. stated, ""Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) Rocephin to 1 grm (gram) IV q (every) 24 hr x 7 days, Zyvox 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE (Vancomycin-resistant Enterococcus) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound contact precautions maintained QS (every shift)."" - Review of Resident #16's medication administration record (MAR), with the registered nurse (RN) unit manager for the East wing on the afternoon of 10/26/11, revealed an ""X"" where a nurse was to have initialed the MAR to indicate the first dose of IV Rocephin had been administered on 10/11/11. The East wing unit manager said the resident had a med port (IV access) and that all the initials on the other days of administration were from RNs. She commented that an RN would have had to administer all the IV doses. She looked at the ""X"" and said this meant the Rocephin was not administered on that date. She said she did not know why it was not given. - On the afternoon of 10/27/11, the director of nursing (DON - Employee #12) also reviewed the resident's MAR and said she, too, did not know why the dose of IV Rocephin scheduled for 10/11/11 was not given. In a subsequent interview on 10/27/11 at approximately 1:50 p.m., the DON confirmed Resident #16 had arrived at the facility on 10/10/11 and should have received a dose of Rocephin on 10/11/11 but did not. According to the DON, the facility did not have this medication available for administration on 10/11/11. -- b) Resident #59 Record review revealed this [AGE] year old male had been admitted to the facility for aftercare of a surgically repaired hip fracture on 06/25/11. He was ordered Lovenox 40 mg/0.4 ml solution subcutaneously (SQ) everyday for a personal history of venous thrombosis and embolism on 06/25/11. An order in the medical record revealed the administration of Lovenox was placed on hold on 10/05/11 due to the medication not being available from the pharmacy. It was then discontinued on 10/06/11. In an interview with the family nurse practitioner (FNP) on 10/27/11 at 2:05 p.m., she recalled the resident had done well after his surgery and was almost as mobile as he had been prior to the intervention. The facility had contacted her on 10/05/11 and explained the medication was unavailable from pharmacy, and she instructed them to put it on hold. The next day, on 10/06/11, it was discontinued. She reported that it was not going to hurt the resident if the medication was not available, since he was up and about and had done well in physical therapy. Regarding the missed dose of Lovenox on 10/05/11, on 10/27/11 at 3:00 p.m., the director of nursing (DON - Employee #12) stated the facility's policy directed staff to obtain the medication from the emergency drug box if a dose was not available in the medication cart for administration to the resident; the DON acknowledged that staff failed to do this for the 10/05/11 scheduled dose of Lovenox. Instead, staff contacted the FNP, who placed a hold on the medication. Staff did not retrieve a dose of Lovenox from the emergency drug box when there was still an active order for the drug's use at the time. .",2014-12-01
10700,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,428,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities found in the medication regimen of one (1) of forty-five (45) Stage II sample residents. One (1) resident had a drug prescribed without a supporting diagnosis, and this was not identified by the consultant pharmacist. Resident identifier: #159. Facility census: 105. Findings include: a) Resident #159 On 08/09/11 at approximately 10:25 a.m., medical record review for Resident #159 revealed she received the medication Mirapex 1 mg po (by mouth) twice a day everyday for Parkinson's disease since 08/18/10. Further medical record review found the resident did not have an active [DIAGNOSES REDACTED]. Interviews with Employee #27A (the director of nursing - DON) and Employee #28A (a registered nurse consultant) revealed no supporting [DIAGNOSES REDACTED]. Review of the resident's most recent medication regimen review by the consultant pharmacist, dated 07/13/11, found no irregularities were identified. .",2014-12-01
10701,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,278,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure the minimum data set assessment (MDS) contained accurate information for one (1) of forty-five (45) Stage II sample residents with respect to the number of falls that the resident had experienced since she was admitted to the facility. Resident identifier: #214. Facility census: 105. Findings include: a) Resident #214 Record review revealed this resident was admitted on [DATE]. Review of the medical record found Resident #214 had fallen on 07/23/11. Observation, on 07/26/11, found this resident had fallen from her bed to the floor, and a licensed practical nurse (LPN - Employee #13) was there with her waiting until someone could help get the resident out of the floor. Review of her Medicare 5-Day MDS, with an assessment reference date (ARD) of 07/26/11, found Section J was encoded to indicate the resident had experienced a fall in the last month prior to admission. In response to a question about whether the resident had any falls since admission or the prior assessment (whichever was more recent), the assessor encoded ""yes"" and noted the resident had one (1) fall with no injury. This was not correct, since the assessment reference period for this assessment would include events that occurred on 07/26/11. .",2014-12-01
10702,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,246,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide reasonable accommodations to one (1) randomly observed resident and two (2) of twenty-one (21) sampled residents. Resident #72's bed did not accommodate the resident's height. Resident #4's neck collar did not allow the resident to eat without difficulty, and he was not consistently provided with adaptive eating utensils to facilitate self-feeding. Resident #137 did not have an appropriately sized wheelchair. Resident identifiers: #72, #4, and #137. Facility census: 138. Findings include: a) Resident #72 Observation, on 08/19/09 at 10:00 a.m., found the resident's feet dangled over the end of the bed. The resident's feet were also in a downward position. An interview with a licensed practical nurse (LPN - Employee #106), on 08/19/09 at 10:10 a.m., revealed the resident was tall and needed to pulled up in bed. The bed was observed to have 2 inches of head room at the top of the bed. If staff positioned the resident by pulling the resident up in bed, this would not alleviate the problem of the resident's dangling feet. Medical record review disclosed the resident's height was 68 inches, and he had a [DIAGNOSES REDACTED]. The resident had foot drop, which required his feet to be elevated and positioned to prevent further problems. b) Resident #4 A random observation, on 08/17/09 at 1:00 p.m., found Resident #4 sitting in a wheelchair wearing a hard cervical collar on his neck. A meal tray was on the overbed table, and because of the rigid collar, Resident #4 had difficulty finding his food and using his eating utensils. No staff was observed to be assisting the resident with his meal. On 08/17/09 at 2:30 p.m., medical record review noted that, on 08/13/09, the resident was sent from another rehabilitation hospital with a suggestion to use red handled utensils for eating, which had been supplied by the transferring facility. The medical record also contained an order for [REDACTED]. On 08/18/09, during observations of meal tray preparation, red handled built-up utensils were noted to be available in the kitchen but not supplied to the resident. At this meal, the resident was observed to be in a geri chair and struggling to see his food. Once supplied with the red handled utensils, he grasped the spoon easier with enhanced manual dexterity, but the visual field remained an issue. During an interview on the afternoon of 08/18/09, the occupational therapist (Employee #153) stated the facility was still in the process of evaluating the resident to determine which adaptive equipment would be best; Employee #153 acknowledged that Resident #4's main problem with self-feeding was not having a clear visual field. c) Resident #137 During an interview on 08/18/09 at 8:50 a.m., the resident stated staff helped her out of bed only once per day and she would like to be up more often for short intervals. She had reported this desire to staff but said it ""goes in one ear and out the other"". Additionally, the resident complained about her wheelchair, stating the wheels did not turn well for a long time, and it had not been repaired despite her requests. She said being in bed twenty-two (22) hours per day made her weaker and being unable to self-propel in the wheelchair was unfulfilling. Record review revealed a physician's orders [REDACTED]. Also on 08/03/09, the physician ordered nursing to turn the resident every two (2) hours while in bed and get the resident out of bed and in the chair for only two (2) hours at a time. During an interview on 08/20/09 at 9:40 a.m., the plant operations supervisor (Employee #148) stated he had not been informed of Resident #137's wheels needing to be greased, but he would take care of it right away. When interviewed on 08/20/09 at 9:50 a.m., the physical therapist did not believe the wheels on the wheelchair need to be greased, rather it was Resident #137's perception of the problem, noting that Resident #137 wanted to wear slipper socks but she propelled it with her feet better while wearing shoes. The physician therapist had not been able to find a wheelchair to fit her. She said Resident #137 needed a hemi height wheelchair with a 20-inch width, as the resident was short with a large abdominal girth. A nurse (Employee #104) stated, in an interview on 08/20/09 at 10:00 a.m., there was no checklist to note how many times per day or at what time per day the resident had been up out of bed and in the wheelchair. She stated they almost always got her up on day shift and the resident communicated the need to get up in the wheelchair during daily report to the oncoming shift. The nurse did not know how often the resident was up on other shifts unless it was documented in the nurse's notes. She explained the resident may only be up for two (2) hours at a time due to wound healing needs, whereas before the wound the resident was up in the wheelchair most of the day. When interview on 08/20/09 at 10:30 a.m., the director of nursing (DON) said she knew the resident was being restricted to two (2) hour limits of sitting up in the wheelchair due to wound healing needs. She was unaware of the resident's wishes to get up more often for shorter periods of time. During exit, the administrator was informed of physical therapy's inability to find a wheelchair that fit the resident's current needs. No further information was obtained at this time. .",2014-12-01
10703,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,329,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility did not ensure the drug regimens of two (2) of twenty-one (21) sampled residents were free of unnecessary drugs. Resident #76, who had a [DIAGNOSES REDACTED]. Resident #13 was receiving a pain medication in an amount over the recommended dose which was also ineffective in controlling the resident's pain. Facility census: 138. Findings include: a) Resident #76 review of the resident's medical record revealed [REDACTED]. On 07/01/09, the physician ordered an antipsychotic medication of [MEDICATION NAME] 50 mg at bedtime. On 07/22/09, a physician ordered [MEDICATION NAME] 1 mg IM every six (6) hours PRN for forty-eight (48) hours. On 07/30/09, a physician ordered [MEDICATION NAME] 1 mg IM now then may repeat every two (2) hours PRN until calm for forty-eight (48) hours. A nursing note, dated 06/30/09 at 5:30 p.m., indicated, ""Resident crying and screaming she does not want to be here. She is kicking and swinging at the other resident and staff. She does not want anyone in the hallway. Shoves residents out of her way. Physician notified and gave an order for [REDACTED]. A nursing note, dated 07/01/09 at 3:00 a.m., indicated, ""Agitated, slapping and hitting staff at this time. Physician called [MEDICATION NAME] 1 mg IM every 3 hours as needed for 24 hours."" A nursing note, dated 07/21/09 at 8:00 a.m., indicated, ""Resident observed sitting on floor in hall outside of her room."" At 12:00 p.m., ""Resident found kneeling at bedside. Physician notified of fall."" On 07/30/09, the physician was notified of behaviors of crying and kicking at staff and ordered [MEDICATION NAME]. A ""Psychiatric Med Check Follow-up"" (dated 07/01/09) indicated, ""The resident has received [MEDICATION NAME] which just made her more restless. We increased the dose of [MEDICATION NAME], however she continued to deteriorate not respond. Klonopin was added and she received [MEDICATION NAME] which has made her more restless. Therefore, we are just going to discontinue all of that and move on."" The resident received an order for [REDACTED]. b) Resident #13 During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, ""I am so sick at my stomach."" When was asked if she had pain, and she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. Medical record review revealed Resident #13 had an order for [REDACTED]. According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm., for [MEDICATION NAME] indications and dosages: - Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to [MEDICATION NAME] can develop with continued use and that the incidence of untoward effects is dose related. - The usual adult dosage is one (1) or two (2) tablets every four (4) to six (6) hours as needed for pain. The total daily dosage should not exceed eight (8) tablets. Review of the Medication Administration Record [REDACTED]. On 08/17/09 at 3:00 p.m., a licensed nurse (Employee #119), when interviewed at the nursing station, identified that Resident #13's [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments had been on hold for approximately two (2) weeks, and she confirmed Resident #13's oncologist had not been notified that the nausea and pain medications was not effective. Employee #119 also identified Resident #13 was getting two (2) [MEDICATION NAME] tablets every four (4) hours for pain, she had not been eating much, and Employee #119 was not sure if the [MEDICATION NAME] was causing Resident #13's nausea. On the morning of 08/18/09, facility management staff (Employees #138 and #139) were questioned about the high dosage of [MEDICATION NAME] with unrelieved pain and the possibility that the [MEDICATION NAME] may have been causing or contributing to the resident's nausea. The physician was notified, and Resident #13 was started on a [MEDICATION NAME] 25 mg pain patch and [MEDICATION NAME] sulfate liquid medication for pain. .",2014-12-01
10704,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,514,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records for each residents that were complete and/or accurate, as evidenced by an incomplete discharge summary, the medical information of one (1) resident misfiled on the wrong chart, and the Medication Administration Record [REDACTED]. This was evident in the medical records of three (3) of twenty-four (24) sampled residents. Resident identifiers: #141, #33, and #25. Facility census: 138. Findings include: a) Resident #141 Review of Resident #141's discharge summary revealed numerous components had not been completed. The discharge summary contained places to record the date of discharge, time and location of discharge; the name of facility / agency to which released; written discharge instructions were given and to whom; the date of the summary by the nurse who wrote it; the prognosis and the rehabilitation potential as written by the physician; and the provisional and final [DIAGNOSES REDACTED]. All of the aforementioned areas were blank. Additionally, the physician signed and dated this form on 08/06/09. However, the resident was not discharged until 08/13/09. Interview with the administrator, on 08/20/09 at 8:30 a.m., revealed this was the resident's final discharge summary for the physician to complete. She acknowledged it was not fully completed by the physician. b) Resident #33 Review of Resident #33's medical record, at 3:50 p.m. on 08/18/09, disclosed the physician's progress notes for another resident (#37) on his chart. The charge nurse of the unit was informed and removed Resident #37's records from Resident #33's chart. c) Resident #25 Medical record review, on 08/19/09, revealed the MAR for 08/08/09 had several blank areas. The column for initialing having administered the 8:00 a.m. dose of [MEDICATION NAME] was left blank; however, an audit of the number of medication doses on hand indicated the 8:00 a.m. doses had been given. Employee #95 (the chief nursing officer) also agreed the medication was given. Additionally, column for recording administration of ordered 150 cc flushes of water via gastrotomy tube was left blank. .",2014-12-01
10705,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,225,E,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to verify the status of employees on the State nurse aide registry concerning findings of abuse, neglect, mistreatment of [REDACTED]. This was evident for four (4) of five (5) sampled employees who had worked with the facility for greater than one (1) year, and for four (4) of five (5) sampled employees who have been recently hired. Staff identifiers: #1, #22, #33, #97, #125, #130, #150, and #155. Facility census: 138. Findings include: a) Employees #125, #33, #22, #155, #1, #97, #130, and #150 The personnel files of Employees #125, #33, #22, and #155, all of whom were recent hires by the facility, contained no evidence of verification with the WV Nurse Aide Abuse Registry in order to ensure there were no findings against them for abuse, neglect, mistreatment of [REDACTED]. The personnel files of Employees #1, #97, #130, and #150, all of whom worked at the facility for greater than one (1) year, also contained no evidence of verification with the Nurse Aide Abuse Registry. On 08/18/09 at approximately 2:30 p.m., the human resource director (Employee #8) and the administrator stated the facility checked the WV Nurse Aide Abuse Registry only for persons employed as nursing assistants, but not for licensed practical nurses, registered nurses, dietary employees, housekeeping employees, maintenance employees, etc., any of whom may have had previous employment as a nursing assistant with a finding of abuse, neglect, etc. On 08/19/09 at approximately 1:00 p.m., the assistant director of nursing (Employee #139) had no further information to provide, when informed of the above findings regarding the facility not having had all employees verified with the WV Nurse Aide Abuse Registry. --- Part II -- Based on record review and staff interview, the facility failed to obtain the required statewide criminal background check on every employee in an effort to uncover past criminal convictions which would indicate they were unfit for duty in a nursing facility. This was noted for five (5) of five (5) sampled employees, who were recently hired by the facility. Employee identifiers: #83, #125, #22, #33, and #155. Facility census: 138. Findings include: a) Employees #83, #125, #33, #22, and #155 On 08/18/09 at approximately 11:00 a.m., review of five (5) randomly sampled personnel records of recently hired employees found these employees had Federal Bureau of Investigation (FBI) background checks, but there was no evidence of the West Virginia State Police background checks having been completed. During an interview at that time, the human resources director (Employee #8) stated the facility does not utilize the West Virginia State Police for background checks of new employees. On 08/18/09 at approximately 2:30 p.m., the Employee #8 and the administrator stated the facility utilized the FBI fingerprinting and background checks instead of the West Virginia State Police background checks, because the facility is geographically located in an area where potential new hires can come from three (3) states. Neither the human resource director nor the administrator was not able to attest with certainty the FBI background checks contained information obtained by the West Virginia State Police database. .",2014-12-01
10706,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,157,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure a resident's oncologist was notified when both pain and nausea medications were not effective. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, ""I am so sick at my stomach."" When asked if she had pain, she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had a abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her nausea, and he increased the frequency from of that medication from every eight (8) hours to every four (4) hours for nausea. -- According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm, [MEDICATION NAME] is indicated for use for the following: - Prevention of nausea and vomiting associated with highly [MEDICAL CONDITIONS], including cisplatin ? 50 mg/m?. - Prevention of nausea and vomiting associated with initial and repeat courses of moderately [MEDICAL CONDITIONS]. - Prevention of nausea and vomiting associated with radiotherapy in patients receiving either total body [MEDICAL CONDITION], single high-dose fraction to the abdomen, or daily fractions to the abdomen. - Prevention of postoperative nausea and/or vomiting. As with other antiemetics, routine [MEDICATION NAME] is not recommended for patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and/or vomiting must be avoided postoperatively, [MEDICATION NAME] Tablets, [MEDICATION NAME][MEDICATION NAME](orally disintegrating tablets), and [MEDICATION NAME] Oral Solution are recommended even where the incidence of postoperative nausea and/or vomiting is low. The facility failed to contact the resident's oncologist in order to inform him that the [MEDICATION NAME] was not effective for nausea, especially since this medication is specific to use in conjunction with [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments, which had been placed on hold. -- According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm., for [MEDICATION NAME] indications and dosages: - Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to [MEDICATION NAME] can develop with continued use and that the incidence of untoward effects is dose related. - The usual adult dosage is one (1) or two (2) tablets every four (4) to six (6) hours as needed for pain. The total daily dosage should not exceed eight (8) tablets. Review of the Medication Administration Record [REDACTED]. On 08/17/09 at 3:00 p.m., a licensed nurse (Employee #119), when interviewed at the nursing station, identified that Resident #13's [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments had been on hold for approximately two (2) weeks, and she confirmed Resident #13's oncologist had not been notified that the nausea and pain medications were not effective. Employee #119 also identified Resident #13 was getting two (2) [MEDICATION NAME] tablets every four (4) hours for pain, she had not been eating much, and Employee #119 was not sure if the [MEDICATION NAME] was causing Resident #13's nausea. The facility failed to contact the oncologist when Resident #13 was experiencing unrelieved pain and nausea, in order to identify alternative interventions. 2. On 08/17/09, following surveyor intervention, the oncologist was called and the nausea medication was changed to [MEDICATION NAME] 10 mg by mouth three (3) times a day. When interviewed on the morning of 08/18/09, Resident #13 related that the new nausea medication was working and this was the first time in days she was not nauseated. 3. On the morning of 08/18/09, facility management staff (Employees #138 and #139) were questioned about the high dosage of [MEDICATION NAME] with unrelieved pain and the possibility that the [MEDICATION NAME] may have been causing or contributing to the resident's nausea. The physician was notified, and Resident #13 was started on a [MEDICATION NAME] 25 mg pain patch and [MEDICATION NAME] sulfate liquid medication for pain. On 08/19/09, following an outside appointment, observation found Resident #13 resting quitely in bed with no grimacing, guarding, or nausea noted. .",2014-12-01
10707,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,281,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, one (1) of twenty-one (21) sampled residents, to ensure a medication was properly administered. A nurse administered via gastrotomy tube a medication that was not recommended to be crushed. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 Medication observation, completed on the morning of 08/19/09, found on Resident #25's Medication Administration Record [REDACTED]. However, the order on the MAR failed to indicate this medication was sustained release. Review of the actual medication contained in the cart found it was [MEDICATION NAME] SR (sustained release). At 9:00 a.m., the dispensing pharmacy was called, and the pharmacist (Employee #154), when interviewed, identified that the medication supplied to Resident #25 was extended release and should not be crushed for administration via the gastrotomy tube. Subsequent review of the MAR indicated [REDACTED]. According to http://www.rxlist.com/[MEDICATION NAME]-sr-drug.htm: ""It is particularly important to administer [MEDICATION NAME] SR Tablets in a manner most likely to minimize the risk of [MEDICAL CONDITION] (see Warnings). Gradual escalation in dosage is also important if agitation, motor restlessness, and [MEDICAL CONDITION], often seen during the initial days of treatment, are to be minimized. If necessary, these effects may be managed by temporary reduction of dose or the short-term administration of an intermediate to long-acting sedative hypnotic. A sedative hypnotic usually is not required beyond the first week of treatment. [MEDICAL CONDITION] may also be minimized by avoiding bedtime doses. If distressing, untoward effects supervene, dose escalation should be stopped. [MEDICATION NAME] SR should be swallowed whole and not crushed, divided, or chewed. .",2014-12-01
10708,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,309,G,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure that care and services were provided for a resident who was experiencing unrelieved pain and nausea. This caused physical and emotional harm to Resident #13. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, ""I am so sick at my stomach."" When was asked if she had pain, and she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had an abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast, abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, the attending physician was notified the medication [MEDICATION NAME] was not effective in relieving the resident ' s pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her attending physician was notified the medication [MEDICATION NAME] was not effective in relieving the resident ' s nausea. The attending physician increased the frequency of [MEDICATION NAME] from every eight (8) hours to every four (4) hours for nausea. -- According to , [MEDICATION NAME] is indicated for use for the following: - Prevention of nausea and vomiting associated with highly [MEDICAL CONDITIONS], including cisplatin ? 50 mg/m?. - Prevention of nausea and vomiting associated with initial and repeat courses of moderately [MEDICAL CONDITIONS]. - Prevention of nausea and vomiting associated with radiotherapy in patients receiving either total body [MEDICAL CONDITION], single high-dose fraction to the abdomen, or daily fractions to the abdomen. - Prevention of postoperative nausea and/or vomiting. As with other antiemetic, routine [MEDICATION NAME] is not recommended for patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and/or vomiting must be avoided postoperatively, [MEDICATION NAME] Tablets, [MEDICATION NAME][MEDICATION NAME](orally disintegrating tablets), and [MEDICATION NAME] Oral Solution are recommended even where the incidence of postoperative nausea and/or vomiting is low. The facility failed to contact the resident's oncologist in order to inform him that the [MEDICATION NAME] was not effective for nausea, especially since this medication is specific to use in conjunction with [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments, which had been placed on hold. -- According to ., for [MEDICATION NAME] indications and dosages: - Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to [MEDICATION NAME] can develop with continued use and that the incidence of untoward effects is dose related. - The usual adult dosage is one (1) or two (2) tablets every four (4) to six (6) hours as needed for pain. The total daily dosage should not exceed eight (8) tablets. Review of the Medication Administration Record [REDACTED]. On 08/17/09 at 3:00 p.m., a licensed nurse (Employee #119), when interviewed at the nursing station, identified that Resident #13's [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments had been on hold for approximately two (2) weeks, and confirmed that Resident #13's was receiving two (2) [MEDICATION NAME] tablets every four (4) hours for pain, she had not been eating much, and Employee #119 was not sure if the [MEDICATION NAME] was causing Resident #13's nausea. The facility failed to contact the attending physician when Resident #13 was experiencing unrelieved pain and nausea following the 07/30/09 and 08/14/09 orders. 2. On 08/17/09, following surveyor intervention, the oncologist was called and the nausea medication was changed to [MEDICATION NAME] 10 mg by mouth three (3) times a day. When interviewed on the morning of 08/18/09, Resident #13 related that the new nausea medication was working and this was the first time in days she was not nauseated. 3. On the morning of 08/18/09, facility management staff (Employees #138 and #139) were questioned about the high dosage of [MEDICATION NAME] with unrelieved pain and the possibility that the [MEDICATION NAME] may have been causing or contributing to the resident's nausea. The attending physician was notified, and Resident #13 was started on a [MEDICATION NAME] 25 mg pain patch and [MEDICATION NAME] sulfate liquid medication for pain. On 08/19/09, following an outside appointment, observation found Resident #13 resting quietly in bed with no grimacing, guarding, or nausea noted.",2014-12-01
10709,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,406,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined that the facility failed to assure that the rehabilitation services department provided effective interventions in a timely manner to promote independence in eating for one (1) of twenty-one (21) sampled residents with known difficulties in self-feeding. Resident identifier: #4. Facility census: 138. Findings include: a) Resident #4 A random observation, on 08/17/09 at 1:00 p.m., found Resident #4 sitting in a wheelchair wearing a hard cervical collar on his neck. A meal tray was on the overbed table, and because of the rigid collar, Resident #4 had difficulty finding his food and using his eating utensils. No staff members were observed to be assisting the resident with his meal. On 08/17/09 at 2:30 p.m., medical record review noted that, on 08/13/09, the resident was admitted to the facility from a rehabilitation hospital with a suggestion to use red handled utensils for eating, which had been supplied by the transferring facility. The medical record also contained an order for [REDACTED]. On 08/18/09, during observations of meal tray preparation, red handled built-up utensils were noted to be available in the kitchen but not supplied to the resident. At this meal, the resident was observed to be in a geri chair and struggling to see his food. Once supplied with the red handled utensils, he grasped the spoon easier with enhanced manual dexterity, but the visual field remained an issue. During an interview on the afternoon of 08/18/09, the occupational therapist (Employee #153) stated the facility was still in the process of evaluating the resident to determine which adaptive equipment would be best; Employee #153 acknowledged that Resident #4's main problem with self-feeding was not having a clear visual field. There was no evidence that the rehabilitative department developed and implemented interventions to address the resident ' s inability to self-feed due not being able to see his food. .",2014-12-01
10710,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,425,F,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to provide pharmaceutical services to meet the needs of each resident and failed to ensure the in-house pharmacy and the consultant pharmacist put in place systems, in accordance with State law, to ensure each resident received medications in the appropriate form and/or irregularities were promptly identified and mitigated. This deficient practice affected one (1) of twenty-one (21) sampled residents and had the potential to affect all residents receiving pharmaceutical services from the facility. Resident identifier #25. Facility census: 138. Findings include: a) Resident #25 Observation, during medication administration on the morning of 08/19/09, revealed the in-house pharmacy sent two (2) medications for Resident #25 (who received his medications via gastrostomy tube) that were not to be open and crushed (Wellbutrin SR and Avocat). A telephone interview with the pharmacist (Employee #154), on 08/19/09 at 9:00 a.m., verified Wellbutrin SR should not be crushed and placed down a gastrotomy tube. An audit of the medication drawer in conjunction with Resident #25's Medication Administration Record [REDACTED]. This review revealed the in-house pharmacy and the consultant pharmacist did not have a system in place to ensure appropriate medications were given and to promptly identify possible irregularities. On 08/19/09 at 10:00 a.m., a review of the facility's policy and procedure manual for pharmaceutical services including the duties of the consultant pharmacist, titled Organizational Aspects IA1-1 (effective date 08/01/08) revealed the following expectations of the consultant pharmacist: - Performing and initial medication use assessment for each new resident - Maintaining a medication profile on each resident that includes all medications dispensed and facility -provided information such as resident's age, diagnosis, condition, medication allergies [REDACTED]. - Screening each new medication order for medication interactions ordered for the resident; for duplication of therapy with other drugs in the same therapeutic class ordered for the resident; and for appropriate drug dosage, dosing interval, and route of administration, based on the residents and other pertinent variables. - Assisting in the assessment and improvement in nursing staff medication administration, including infusion therapy and use of medication delivery and testing devices, through medication pass observation and through medication record reviews. - Assisting in establishing quality assurance and continuous quality improvement (CQI) activities regarding the medication process; prescribing; dispensing; storing; administering; and monitoring of medications in the facility. On 08/19/09 at 11:00 a.m., the facility's administrator (Employee #6) produced information obtained from the consultant pharmacist which included a detailed list of each resident with the drug review summary completed for July 2008 and a cycle exchange which included information such as expired medications, refrigerator temperature, medications to expire soon, and medications loose in the cart and not in assigned package. According to Title 15 Legislative Rule West Virginia Board of Pharmacy Series 1 Rules and Regulations of the Board of Pharmacy, the responsibilities of a consultant pharmacist are as follows: 23.4. Responsibilities. 23.4.1. A pharmacist consultant shall document by date and time, in a permanent log book, his or her activities for each place where he or she is registered. This log book shall be present in each facility for which the consultant pharmacist is registered and shall be available for inspection by the Board at any time. 23.4.2. The pharmacist consultant shall initiate and maintain, in each facility, appropriate records and procedures for the receipt, storage and disposition of all drugs including but not limited to: prescriptions; floor stock; emergency boxes or kits; investigational drugs; samples; and outdated or discontinued drugs. 23.4.3. The pharmacist consultant shall maintain a Policy and Procedures Manual for pharmaceutical services. The Manual shall be available to all inspectors and available to patient care providers for their guidance in drug handling. The manual shall include, but not be limited to, provisions for the following: transcribing drug orders and prescription ordering; prescription delivery system and in-house verification; drug recall; automatic stop orders; formulary or standards for drug quality; systematic review of drug orders; reconciliation of controlled substances; disposition by the following means of prescriptions not totally consumed by the patient: return to pharmacy for credit; and destruction by the pharmacist in the presence of a registered nurse; and in-service drug education of other personnel. 23.4.4. The pharmacist consultant shall maintain an appropriate drug reference library for use by other health care personnel. 23.4.5. The pharmacist consultant shall insure compliance with all applicable laws and regulations, both state and federal. 23.4.6. The pharmacist consultant shall make every effort to separate consulting duties from dispensing duties. Remuneration shall be comparable to that charged by a pharmacist consultant not associated with the supplier of drugs or devices. The pharmacist or his or her employer shall receive remuneration directly from the facility to which he or she is providing the service. If the pharmacist consultant has any financial interest in the pharmacy providing drugs or devices to the facility he or she may not provide the consulting service in order to obtain an agreement to be the supplier. 23.4.7. Nothing in this rule precludes a patient in a skilled or intermediate nursing facility, or other voluntarily entered facility, from free choice of pharmacy services. The facility failed to ensure the in-house pharmacy and the consultant pharmacist put in place systems, in accordance with State law, to ensure each resident received medications in the appropriate form and/or irregularities were promptly identified and mitigated. .",2014-12-01
10711,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,152,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the determination of incapacity, for one (1) of twenty-one (21) sampled residents, was documented in accordance with State law. Resident #106's record lacked any information regarding the cause or nature of the incapacity as required by W.Va. Code 16-30-7(b). Additionally, there was no evidence the resident was notified of the determination of incapacity as required by W.Va. Code 16-30-7(c). Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 According to the medical record, the resident was admitted to the facility on [DATE]. A ""Physician's Determination of Capacity"" form, completed by the attending physician on 04/23/08, indicated the resident ""Demonstrates INCAPACITY to make medical decisions"" for a ""Short term"" duration. The form listed ""sequelae of [MEDICATION NAME] toxicity"" without additional explanation as to the nature or cause of the resident's incapacity. Additionally, no evidence could be found the physician informed this conscious resident of the determination of incapacity or of the fact that a surrogate decision-maker would be acting on the resident's behalf. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged, after reviewing the resident's determination of incapacity, the documentation was incomplete. b) Per W.Va. Code 16-30-7. Determination of incapacity. ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10712,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,159,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to obtain written authorization from the legal representative for financial decisions for one (1) of twenty-one (21) sampled residents and one (1) resident of random opportunity, both of whom had been determined to lack the capacity to understand and make medical decisions and whose personal funds were held and managed by the facility. Resident identifiers: #106 and #5. Facility census: 138. Findings include: a) Resident #106 According to the medical record, Resident #106 was admitted to the facility on [DATE], and was determined to lack the capacity to understand and make medical decisions on 04/23/08. He signed his own admission information, which did not include an authorization for handling of personal funds. The resident had a durable power of attorney (DPOA), but there was no evidence the DPOA signed an authorization for the facility to handle the resident's personal funds. During an interview with the person responsible for handling resident funds at 10:00 a.m. on 08/19/09, she acknowledged there was no written authorization on file but stated that new forms had been developed and signatures had been obtained after the previous resurvey. She would look for them. At 08:30 a.m. on 08/20/09, the administrator presented the mislaid authorization form signed by the resident, but the date of the authorization was September 2008, which was after the resident had been determined to be incapacitated. b) Resident #5 Medical and financial records of Resident #5 revealed she had been determined to lack the capacity to make health care decisions, and her son had been named her health care surrogate (HCS). The HCS, who was not the legal power of attorney for financial decision-making, was permitted to sign the form authorizing the facility to deposit and handle the resident's personal funds, which included a pension not associated with the social security program. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged there was no evidence Resident #5 had a legal representative with the authority to make financial decisions on her behalf. --- Part II -- Based on record review and staff interview, the facility failed to ensure two (2) residents, whose stays were covered by Medicaid, were notified when the amounts in their personal funds accounts had reached $1800.00. Resident identifiers: #63 and #74. Facility census: 138. Findings include: a) Resident #63 Review of the financial record of Resident #63 revealed a personal account balance of $1937.72, but there was no evidence the resident's POA had been notified. b) Resident #74 Review of the financial record of Resident #74 revealed a personal account balance of $1914.46, but there was no evidence the resident's conservator had been notified. c) During an interview at 4:00 p.m. on 08/19/09, the administrator agreed there was no documentation of notification but maintained the office clerk did call them. .",2014-12-01
10713,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,250,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to re-evaluate a resident's determination of incapacity to make informed decisions about health care after a determination made shortly after admission to the facility, in 2008, indicated the resident's incapacity was of a short-term duration. This affected one (1) of twenty-one (21) sampled residents. Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 Clinical record review disclosed Resident #106 was a [AGE] year-old male admitted on [DATE], with [DIAGNOSES REDACTED]. On 04/23/08, the resident was determined to lack capacity to make medical decisions by his physician for a short-term duration without a stated cause other than the [DIAGNOSES REDACTED]. There was no reassessment of the resident's capacity, although a determination of capacity form was in the record and signed by the physician on 09/03/09. During an interview at 11:00 a.m. on 08/05/09, the social worker stated that, usually, short-term determinations of capacity were re-assessed after three (3) months, and this one had just been overlooked. .",2014-12-01
10714,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,272,D,0,1,S2JZ11,"**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 minimum data set assessment (MDS) for one (1) of twenty-one (21) residents on the sample whose ability to verbally communicate with others was impaired. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 According to the medical record, Resident #25 was an [AGE] year-old male admitted on [DATE], following hospitalization for injuries sustained in a fall at home. Prior to his fall, he lived with his spouse at home and was self-sufficient. Admission [DIAGNOSES REDACTED]. Medical record review also disclosed the resident was admitted with severe dysphagia, making a PEG tube necessary for nutrition because of an inability to swallow and the need for intermittent suctioning to clear oral secretions. The resident wore a Miami J neck collar when sitting up. On 07/18/09, a nurse noted the resident could verbally communicate by ""...whispers but you can understand."" On 07/22/09, a nursing note documented, ""....you have to listen to him closely."" The information in the nursing notes was verified with the assistant director of nurses (ADON) during an interview at 3:15 p.m. on 08/18/09. The admission MDS of 07/24/09 and the 14-day MDS of 07/29/09 indicated, at Items C4 and C5, that the resident had ""clear speech"" and was always ""understood"" by others. During an interview with the MDS coordinator and the director of nurses (DON) at 3:45 p.m. on 08/19/09, concerns related to the resident's ability to verbally communicate to others were discussed with the result that they would review the chart and return the following morning. On the morning of 08/20/09, the DON and ADON acknowledged the resident had communication problems that were not accurately reflected on the MDS assessments. .",2014-12-01
10715,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,279,D,0,1,S2JZ11,"**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 and nursing interventions to address all identified problems for one (1) of twenty-one (21) sampled residents. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 According to the medical record, Resident #25 was an [AGE] year-old male admitted on [DATE], following hospitalization for injuries sustained in a fall at home. Prior to his fall, he lived with his spouse at home and was self-sufficient. Admission [DIAGNOSES REDACTED]. Medical record review also disclosed the resident was admitted with severe dysphagia, making a PEG tube necessary for nutrition because of an inability to swallow and the need for intermittent suctioning to clear oral secretions. The resident wore a Miami J neck collar when sitting up. On 07/18/09, a nurse noted the resident could verbally communicate by ""...whispers but you can understand."" On 07/22/09, a nursing note documented, ""....you have to listen to him closely."" The information in the nursing notes was verified with the assistant director of nurses (ADON) during an interview at 3:15 p.m. on 08/18/09. The communication needs of this resident are not addressed in his care plan and the necessary interventions are not being communicated through the care plan to all care givers. The physician determined, on 07/27/09, the resident lacked the capacity to make informed health care decisions, and his medical power of attorney representative (MPOA) was making health care decisions on his behalf (as evidenced by her signature in the record), but no care plan was developed to address his change in cognitive status. During an interview with the MDS coordinator and the director of nurses (DON) at 3:45 p.m. on 08/19/09, concerns related to the resident's ability to verbally communicate to others were discussed with the result that they would review the chart and return the following morning. On the morning of 08/20/09, the DON and ADON acknowledged the resident had communication problems and agreed that these problems and his changes in cognition should be addressed in the plan of care. .",2014-12-01
10716,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,285,B,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of a new resident were evaluated prior to admission through the State-mandated pre-admission screening tool, the form PAS-2000. This was evident for two (2) of twenty-four (24) residents on the sample. Resident identifiers: #33 and #140. Facility census: 138. Findings include: a) Resident #33 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 03/17/09, as indicated by the dated signature in Section V of the form PAS-2000. b) Resident #140 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 07/08/09, as indicated by the dated signature in Section V of the form PAS-2000. c) In an interview at 2:40 p.m. on 08/19/09, the facility's three (3) social workers acknowledged the Level II determinations occurred after admission for both residents. .",2014-12-01
10717,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-08-22,278,D,1,0,08RC11,"**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 a weight recorded in the minimum data set assessment for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE] and was readmitted to the facility following a hospital stay on 05/23/11, weighed 87 pounds (#) on 05/25/11; this was recorded on sheet containing nothing but weights found in the medical record. Review of this resident's initial minimum data set assessment (MDS), with an assessment reference date of 05/29/11, found the assessor recorded the resident's weight as being 132# during this assessment reference period. During an interview on 08/17/11 at 3:30 p.m., the dietary manager (Employee #63) verified that she completed this section on this MDS. She stated she knew this weight of 185# was not accurate, because this resident never weighed 132#. She stated this must have been a data entry error, because she kept a close eye on this resident's weight and the resident never weighed that much. .",2014-12-01
10718,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-08-22,279,D,1,0,08RC11,"**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 the results of a comprehensive assessment for one (1) of six (6) sampled residents. Resident #185's assessment identified his weight as 129 pounds (#). His care plan contained a goal for him to maintain his weight between 175# and 195#. This care plan was not based his assessment information. Resident identifier: #185. Facility census: 180. Findings include: a) Resident #185 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. According to his nursing admission assessment dated [DATE], he weighed 130 pounds (#) on admission. According to his weight record, subsequent weights were as follows: 129.2# on 05/31/11; 128# on 06/03/11; and 126.2# on 07/03/11. Further review of the medical record found a Medicare 14-Day minimum data set assessment (MDS) with an assessment reference date of 06/01/11, which stated, in Section K0200, that this resident's weight was 129#. The assessor indicated the resident had not experienced a significant weight loss of five percent (5%) in the last month or ten percent (10%) in the last six (6) months. The assessor further indicated that the received received fifty-one percent (51%) or greater of his total daily calories through his feeding tube. Review of a hospital record titled ""Outside Facility Transfer Form"" dated 05/19/11, the resident's weight was 185#. In another hospital record (a progress note by the hospital's dietician dated 05/19/11 at 9:11 a.m.), the resident's weight was 139.7#. The nursing home's consultant dietician completed a medical nutritional therapy review on the resident on 05/25/11. This assessment stated the resident's weight was 185# at that time. Subsequently, his initial comprehensive care plan, which was based on a weight of 185#, contained a goal for him to maintain his weight between 175# and 195#. The director of nursing (DON), when questioned about this resident's weight on 08/22/11 at 11:00 a.m., verified the weight recorded by the facility's consultant dietician on the medical nutritional therapy assessment was incorrect and the weight she used on the care plan did not match the MDS assessment weight. This was greater than a 50# discrepancy. .",2014-12-01
10719,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-08-22,514,D,1,0,08RC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the clinical record contained complete and accurate information about a resident's skin condition for one (1) of six (6) sampled residents (#184). On admission, Resident #184 had a Stage 3 pressure ulcer, which later declined to a Stage 4, and for which she received daily treatments. ""Nursing Daily Skilled Summary"" forms, used by the facility to record assessment information about various body systems, contained check boxes to prompt nurses to record specific information - such as the presence of pressure ulcers. Ten (10) such summary forms, entered in the resident's record between 06/07/11 and 06/24/11, were either left blank or were specifically - and incorrectly - marked ""No problems"". Additionally, although assessments of her wound were being recorded on a pressure ulcer log used to track the wounds of multiple residents simultaneously, Resident #184's own medical record did not contain a weekly description of the characteristics of her wound as it was being assessed between the dates of 07/05/11 and her date of discharge on 07/13/11. Resident identifier: #184. Facility census: #180. Findings include: a) Resident #184 1. Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Assessment information revealed the presence of a Stage 3 pressure ulcer on the resident's coccyx upon her return from the hospital. Review of her physician's telephone orders found an order, dated 05/25/11 at 12:30 p.m., stating (quoted as written): ""(1) Cleanse wound to Coccyx /c (with) [MEDICATION NAME], pat dry, apply Santyl. Cover /c 4x4 [MEDICATION NAME]. (Symbols for ""change every day') and PRN (as needed) until resolved. @ (At) drsg (dressing) (symbol for 'change') complete daily pressure ulcer monitoring record. (2) Ensure drsg is C/D/I (clean / dry / intact) Q (every) shift to Coccyx."" Further review of Resident #184's medical record found a form titled ""Nursing Daily Skilled Summary"", which was being completed daily by a licensed nurse while she received skilled care. Instructions provided on this form directed the nurse to record all abnormal findings in a narrative format in the space provided. Between the dates of 06/07/11 and 06/25/11, there were ten (10) days on which the section intended record an assessment of the resident's skin condition was either not completed or had checkmarks placed in boxes to indicate the presence of ""no problems"" and/or ""scars"" as follows: - 06/07/11 at 11:00 p.m. - ""No problems"" and ""Other - scars"" - 06/08/11 (no time noted) - ""No problems"" and ""Other - scars"" - 06/10/11 at 8:00 p.m. - ""No problems"" and ""Other - scars"" - 06/14/11 at 7:00 p.m. - ""No problems"" and ""Other - scars"" - 06/15/11 at 8:30 p.m. - ""No problems"" - 06/17/11 at 11:00 p.m. - ""No problems"" - 06/18/11 at 2300 (11:00 p.m.) - Skin assessment section was blank. - 06/19/11 at 2300 (11:00 p.m.) - Skin assessment section was blank. - 06/21/11 at 7:00 p.m. - ""Other - ______"" (there was no additional information recorded) - 06/24/11 at 1900 (7:00 p.m.) - Skin assessment section was blank. In the section in which the licensed nurse was to record an additional services being provided, the item labeled ""Wound care and management"" was not checked on any of the above-referenced summaries. Additionally, none of these summaries contained anything in the narrative notes section at the bottom of each form or on the reverse side of each form. -- 2. Further record review found weekly skin records, on which the treatment nurse recorded a description of the wound, including measurements. This was noted to be done weekly until 07/05/11, after which there was no weekly entry. The resident was discharged to home on 07/13/11, and the next weekly skin record should have been recorded on 07/12/11. There was no indication in the medical record that this wound had been assessed since 07/05/11 and prior to her discharge on 07/13/11. This was brought to the attention of the director of nursing (DON) at 2:00 p.m. on 08/22/11. He provided the facility's wound log on which information about all residents' wounds was recorded. The previous week's measurements for each resident's wounds were also recorded on this log, so progress in wound healing could be evaluated. An entry on this log verified that Resident #184's wound was assessed and measured on 07/12/11. The DON stated Resident #184 went home on 07/13/11, and the treatment nurse had not recorded these measurements in the resident's record. There was no documentation in the resident's medical record of the condition of this wound at the time she was discharged .",2014-12-01
10720,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2011-08-22,280,D,1,0,08RC11,"**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 a resident was no longer receiving a gastrostomy tube ([DEVICE]) feeding. The care plan did not reflect the resident's current health status and care needs for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Her care plan, dated 05/30/2011, stated she ""receives enteral nutrition related to impaired swallowing, failure to eat, anorexia, burning mouth syndrome and nausea and vomiting."" Her goal stated she would have nutrition and hydration needs met and maintained with enteral feedings as ordered and stable weights between 87 pounds (#) and 110#. The approaches were focused on the [DEVICE] feeding and monitoring her tolerance of the feeding. Resident #184 was transferred to the hospital on [DATE]; she was having some complications with her [DEVICE], and this was the second time she had been transferred to the hospital since her admission due to her [DEVICE] coming out. She was receiving speech therapy at that time and had been receiving some foods by mouth. When she returned from the hospital on [DATE], she was no longer receiving feedings by [DEVICE] but had an order for [REDACTED]. The care plan, upon her return from the hospital on [DATE], continued to identify this resident as receiving enteral nutrition. It was not updated to reflect that she was receiving food by mouth as her primary source of nutrition. The dietary manager (Employee #63), when interviewed at 3:30 p.m. on 08/17/11, verified that the care plan should have been updated when the resident returned from the hospital to reflect her current status, because she was receiving a regular diet at that time. Employee #63 verified that she went one (1) week without the tube feeding, and when her intake started to decline, they re-started the feeding. She agreed the care plan was not updated to reflect these changes since her return from the hospital. .",2014-12-01
10721,FAIRHAVEN REST HOME INC,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2011-08-19,441,F,1,0,FPYI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of infection control documentation, medical record review, staff interview, review of West Virginia Bureau for Public Health Guidelines for Scabies Outbreaks in Institutions, Health Care Facilities, Prisons, Dormitories, Shelters (published August 2010), review of facility policy related to scabies, and interview with a representative of the county health department, the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. The facility failed to appropriately investigate, control, and prevent the spread of a scabies infection in the facility. The facility provided treatment for [REDACTED]. The facility failed to screen residents for signs and symptoms of scabies infection in accordance with physician orders. The facility failed to notify the local health department concerning the outbreak of scabies in their facility in accordance with the West Virginia Bureau for Public Health Guidelines. When the local health department contacted the facility based upon an anonymous report, the facility provided inaccurate information related to the scabies outbreak in their facility. This deficient practice affected six (6) of forty-one (41) residents and eleven (11) of seventy-three (73) employees. Resident identifiers: #42, #13, #15, #27, #14, and #32. Employee identifiers: #51, #23, #31, #33, #43, #44, #51, #46, #15, #22, and #37. Facility census: 41. Findings include: Findings include: a) The acting interim administrator (Employee #9) provided evidence that Employee #51 (in housekeeping) received treatment for [REDACTED]. Review of the medical record found Resident #42 was admitted to an acute care facility for an acute change of condition on 07/22/11. She returned to the facility on [DATE], with a discharge summary documenting the resident presented with itching and received treatment for [REDACTED]. She was discharged back to the hospital on [DATE], when her respiratory status deteriorated. Information provided by the infection control nurse (Employee #13), on the afternoon of 08/18/11, revealed Employee #23 (a licensed practical nurse - LPN) and Employee #31 (a nursing assistant) received treatment for [REDACTED]. A review of medical records, and an afternoon interview on 08/18/11 with the Employee #13, revealed Residents #13 and #15 received treatment for [REDACTED]. -- Review of West Virginia Bureau for Public Health Guidelines for Scabies Outbreaks in Institutions, Health Care Facilities, Prisons, Dormitories, Shelters, published in August 2010, found the definition of "" outbreak "" consisted of two (2) or more consecutive cases of scabies among residents / staff within a period of four (4) to six (6) weeks. The facility could provide no evidence that the local health department was notified after a total of six (6) facility staff and residents had been treated for [REDACTED]. -- Further review of the Guidelines for Scabies Outbreaks found the following language: ""When you have an outbreak... 1. Confirm the diagnosis (arrow sign) refer to a physician or consult a dermatologist and report to your local health department. 2. Begin line listing of ill persons (including residents, staff, and close contacts), complete for duration of outbreak (until you have no new case for two incubation periods 6-12 weeks. 3. Conduct a thorough search for atypical / unrecognized cases. ..."" An interview with Employee #13, on the afternoon of 08/18/11, revealed the facility did not begin a line listing of individuals treated for [REDACTED]. -- An order was obtained on 08/01/11 for body checks of facility residents to be conducted every other day for two (2) weeks. Review of the documentation found nursing staff did not document that these body checks were performed. -- A representative from the Assisted Living Program of the Office of Health Facility Licensure and Certification conducted a complaint investigation related to an allegation of a scabies outbreak on 08/03/11. The facility failed to disclose to this surveyor that, at that time, a total of six (6) residents and staff had been treated for [REDACTED]. -- After 08/03/11, three (3) residents and eight (8) staff members received treatment for [REDACTED]. - Review of the medical record found Resident #27 received treatment for [REDACTED]. - Review of the medical record found Resident #14 received treatment for [REDACTED]. - Review of the medical record found Resident #32 received treatment for [REDACTED]. An afternoon interview with Employees #9 and #13, on 08/18/11, revealed the facility had obtained tubes of 5% [MEDICATION NAME] cream from a local pharmacy and distributed this to employees. The facility utilized a handwritten note with employee names and partial names to identify those treated for [REDACTED].#33, #43, #44, #51, #46, #15, #22, and #37 received tubes of the cream; however, the facility was unable to identify or provide information concerning the number of tubes of 5% [MEDICATION NAME] cream from the pharmacy, nor of how many employees received the medication. -- The facility provided a copy of a communication from the facility to the local health department dated 08/16/11. Review of the typed communication found the facility failed to disclose to the local health department that Residents #15, #27, #14, and #13 received treatment for [REDACTED].#42, who had received treatment in the hospital for scabies, returned to the facility; the communication informed the health department that this resident was discharged to home. -- An interview with a representative of the local health department, on the afternoon of 08/19/11, revealed their first knowledge of a possible outbreak of scabies at this facility came from an anonymous call to the health department's hot line - and not from the facility itself.",2014-12-01
10722,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,329,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assess one (1) of six (6) sampled residents for possible underlying causes of the resident's behavior prior to administering a psychoactive medication ([MEDICATION NAME]). Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 3:55 p.m.: ""Vitals were taken temperature 97.3, pulse 107, Respirations 26, blood pressure ,[DATE]."" - On [DATE] at 8:00 p.m.: ""she took her medications without problems no distress was noted. The resident was taking off her oxygen and the nurse instructed her to leave it on. Her oxygen saturation was 93%."" - On [DATE] at 8:30 p.m.: ""Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor."" - On [DATE] at 10:00 p.m.: ""Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]."" - On [DATE] at 12:00 a.m.: ""Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril."" - On [DATE] at 1:20 a.m.: ""cont to yell out and move around in bed - [MEDICATION NAME] given per prn order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt."" - On [DATE] at 2:00 a.m.: ""remains in bed. quiet at present. Requires assist with ADL's, foley patent and draining dark yellow urine."" - On [DATE] at 2:40 a.m.: ""Had light on - nursing assistant went into room - resident asked to be pulled up in bed. oxygen off - replaced pat. was trying to remove oxygen when nursing assistant was putting it on patient stated, 'I don't want this on my face - get this off me.' When nursing assistants were leaving patient yelled out to be turned again on her side. Which was done."" - On [DATE] at 3:00 p.m. (should have been ""a.m.""; error in documentation): ""nursing assistant went into room and sat with pt. per pt. request. some relief noted from [MEDICATION NAME] being given."" - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - no pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L (left) side Body cold and stiff. Resident obviously expired."" - Employee #64 administered [MEDICATION NAME] at 1:20 a.m. on [DATE], without providing non-pharmacological interventions and without making efforts to identify possible underlying causes of the resident's behavior. - Employee #64, when interviewed on [DATE] at 10:30 a.m., related the following: ""She (the resident) was very anxious. I was filling in for an 8 hour shift. When I came in she was screaming and yelling. I checked her oxygen level and her lung sounds. I didn't try to call her husband. I didn't call the doctor, because she already had the [MEDICATION NAME] ordered. After I gave her the [MEDICATION NAME], she calmed down. I don't remember how long the aide sit with her. The aide went to lunch, and she calmed down. I just thought maybe she was anxious. The other nurse did not say she was having any problems before I got her. I thought she was comfort care when she was admitted ; I never looked it up. We have two hour rounds, and she was resting. The [MEDICATION NAME] was effective, so I felt no need to go back. If the [MEDICATION NAME] had not been effective, I would have called the doctor and did something else. I don't usually work night shifts, so I didn't really know the resident."" She further stated, ""I would do things differently now.""",2014-12-01
10723,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,157,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to immediately notify the physician of one (1) of six (6) sampled resident's death. Resident #60 was a full code. She was found by nursing staff with no pulse and no respirations on [DATE]. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Resident #60 had elected to be a full code. Review of the nurses' notes for [DATE] revealed the following entries (quoted as written): - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired."" - On [DATE] at 4:41 a.m.: ""Family was notified of death."" - On [DATE] at 4:42 a.m.: ""Funeral Home was notified of death."" - On [DATE] at 4:44 a.m.: ""Senior vice president was notified of death."" - On [DATE] at 4:45 a.m.: ""Vice president of resident services was notified of death."" - On [DATE] at 5:00 a.m.: ""RN on call was notified of death."" Review of the nursing notes found no evidence that the physician was notified. - On [DATE], interviews were conducted with the following employees: - Employee #52 (certified nursing assistant), when interviewed at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and ""... her tongue was drooped and purplish colored."" He stated he told Employee #73 (certified nursing assistant), ""She looks like she passed away."" He left the room to tell the nurse (Employee #64). - Employee #73, when interviewed at 2:30 p.m., verified she and Employee #52 found Resident #60 around 4:00 a.m. She stated, ""She felt cold and her tongue was hanging out of her mouth."" - Employee #64 (licensed practical nurse) was interviewed at 10:30 a.m. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, ""No, I thought she was comfort measures."" Employee #64 further stated, ""I didn't call the doctor."" - On [DATE] at 9:24 a.m., the director of nursing (Employee #80) stated, ""We do not have to call the physician, we tell him on his next round."" She further stated, ""They do not have to call him if they are a full code."" .",2014-12-01
10724,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,281,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide care to one (1) of (6) sampled residents in accordance with the physician's orders [REDACTED]. Resident #60 had orders to monitor her blood pressure and pulse prior to administering antihypertensive medications; a nurse failed to obtain and record the resident's blood pressure and pulse prior to administering these medications as ordered by the physician. The nurse also failed to record the resident's blood sugar level as indicated on the physician's orders [REDACTED].#60. Facility census: 59. Findings include: a) Resident #60 Review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. No evidence could be found that Employee #70 followed the physician's orders [REDACTED]. Further review of the MAR found initials indicating a nurse obtained Resident #60's blood sugar at 8:00 p.m. on 07/29/11, but there was no record of the blood sugar level itself. Interview with the director of nursing, at 1:00 p.m. on 08/24/11, confirmed Employee #70 did not document a blood sugar, pulse, or blood pressure of Resident #60 for this date and time. .",2014-12-01
10725,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,282,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure qualified nursing staff had knowledge of a resident's code status, for one (1) of six (6) sampled residents. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Record review revealed Resident #60 had elected to be a full code. Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 8:30 p.m.: ""Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor."" - On [DATE] at 10:00 p.m.: ""Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]."" - On [DATE] at 12:00 a.m.: ""Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril."" - On [DATE] at 1:20 a.m.: ""cont to yell out and move around in bed - [MEDICATION NAME] given per prn (as needed) order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt."" - On [DATE] at 2:00 a.m.: ""remains in bed. quiet at present. Requires assist with ADL's (activities of daily living), foley (indwelling urinary catheter) patent and draining dark yellow urine."" - On [DATE] at 2:40 a.m.: ""Had light on - nursing assistant went into room - resident asked to be pulled up in bed. oxygen off - replaced pat. was trying to remove oxygen when nursing assistant was putting it on patient stated, ""I don't want this on my face - get this off me."" When nursing assistants were leaving patient yelled out to be turned again on her side. Which was done."" - On [DATE] at 3:00 p.m. (should have been ""a.m.""; error in documentation): ""nursing assistant went into room and sit with pt. per pt. request. some relief noted from [MEDICATION NAME] being given."" - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired."" Review of the facility's self-reporting of the incident revealed a statement taken on [DATE] from Employee #95, the registered nurse (RN) on call the night of the incident. According to this statement, a licensed practical nurse (LPN - Employee #64) called Employee #95 at 5:00 a.m. on [DATE]. Employee #95 questioned Employee #64 about the resident's code status. Employee #64 stated, ""I forgot to look."" Employee #95's statement also revealed she ""... did not feel comfortable on giving her instructions on what to do since mistake already made. ..."" Employee #95 recommended Employee #64 call the director of nursing (DON). The following staff interviews were conducted: - Employee #64 (LPN) was interviewed at 10:30 a.m. on [DATE]. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, ""No, I thought she was comfort measures. I had no clue that she was going to die. I knew her condition was not good, but I had no idea she was going to die. I thought she was comfort care when she was admitted . I never looked it up."" - Employee #52 (certified nursing assistant), when interviewed on [DATE] at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and, ""... Her tongue was drooped and purplish colored."" He stated he told told employee #73, ""She looks like she passed away."" He left the room to tell the nurse, employee #64. - Employee #73 (certified nursing assistant), when interviewed on [DATE] at 2:30 p.m., stated, ""I checked the resident every two hours after starting my shift. I was in and out of the room because (Resident #60) seemed nervous. Prior to lunch, I sat with her holding her hand; she was calming down and seemed fine. I sat with her probably ten minutes before lunch."" She verified she and Employee #52 found Resident #60 around 4:00 a.m., stating, ""She felt cold and her tongue was hanging out of her mouth. It was probably 45 minutes since I had been in the room."" - Employee #80 (director of nursing), when interviewed on [DATE] at 9:42 a.m., stated, ""The facility reported the incident, because they did not perform CPR on a resident who was a full code."" - Employee #95 (RN on call), when interviewed on [DATE] at 11:06 a.m., stated Employee #64 had called her on the night of the incident, and she verified the statement previously given on [DATE] was correct. .",2014-12-01
10726,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,156,B,0,1,H9I611,". Based on a review of the facility's Medicare demand bill records and staff interview, the facility failed to provide the appropriate beneficiary liability and appeal notices for three (3) of three (3) residents who had recently had their Medicare-covered services terminated. There was no evidence that the facility notified the beneficiary of his/her potential liability for payment and standard appeal rights. This practice affected Resident #40 and had the potential to effect more than an isolated number of residents who received Medicare-covered services. Facility census: 49. Findings include: a) Resident #40 Record review of residents who had received Medicare-covered services in the last three (3) months revealed one (1) demand bill had been requested. This was for Resident #40. The letter used to notify the resident / responsible party that services would no longer be covered by Medicare was a letter designed by the facility which did not contained all required elements found in Form CMS- or one (1) of the five (5) uniform denial letters found in the CMS Skilled Nursing Manual. The letter sent by the facility did not notify the legal representative of the beneficiary's potential liability for payment of the non-covered services. An interview with the staff member responsible for patient accounts (Employee #130) confirmed the facility was not utilizing the CMS forms to notify residents / responsible parties of Medicare non-coverage and of their right to request demand bills, which contained all of the required information for notification to the beneficiary. .",2014-12-01
10727,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,279,D,0,1,H9I611,". Based on observation, record review, and staff interview, the facility failed to develop a care plan to address the oral / dental care needs of one (1) of twenty-three (23) Stage II sample residents. The care plan for Resident #33 did not describe how to provide oral care to this resident, who resisted opening her mouth and clenched her jaws tightly together when the caregivers attempted to perform oral hygiene. Her care plan also did not address the need for an evaluation by a dentist to assure the resident, who had blackened / broken teeth, did not experience pain or impairment in her eating ability as a result of her poor dental status. Resident identifier #33. Facility Census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. The nursing assistant providing care for the resident on 10/13/10 (Employee #50), when interviewed at 5:00 p.m., was questioned about providing oral care for this resident. Employee #50 stated this resident often would not allow her to provide oral care and would clench her mouth tightly so that she could not get inside her mouth. She said, ""You have to just return later and try again because, later, she might let you do it."" She also reported the resident had a growth in the roof of her mouth. Review of the resident's current care plan (which was last reviewed / revised on 09/08/10) found it did not address the oral care. The only approach for her oral status stated, ""Monitor for dental / oral problems or problems with her eyes or ears and notify the physician as indicated, podiatry consult as needed."" This intervention was not appropriate, because there was no accurate baseline assessment of resident's oral status. She had multiple broken, carious teeth had not been identified on assessment, and there was no evidence that the growth in the roof of her mouth had been assessed. The minimum data set assessment (MDS) nurse (Employee #44) verified, during an interview at 4:30 p.m. on 10/13/10, that no care plan had been developed to accurately describe the care and services needed to address this resident's oral hygiene and/or dental needs. .",2014-12-01
10728,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,412,D,0,1,H9I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to identify the need, and arrange dental services, for one (1) of twenty-three (23) Stage II sample residents, to assure she was not experiencing complications (such as pain or infection) related to the poor condition of her oral cavity. This resident was observed to have multiple broken, carious teeth which had not been identified as a concern by the facility, and for which no referral had been made to a dentist for possible intervention. Resident identifier: #33. Facility census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. The nursing assistant providing care for the resident on 10/13/10 (Employee #50), when interviewed at 5:00 p.m., was questioned about providing oral care for this resident. Employee #50 stated this resident often would not allow her to provide oral care and would clench her mouth tightly so that she could not get inside her mouth. She said, ""You have to just return later and try again because, later, she might let you do it."" She also reported the resident had a growth in the roof of her mouth. This resident had [MEDICAL CONDITION] and was not able to communicate her wants and needs to others. She received a pureed diet and often clenched her jaws together when the staff attempted to perform oral hygiene. She was not able to verbalize her needs. Review of the resident's current care plan (which was last reviewed / revised on 09/08/10) found it did not address the oral care. The only approach for her oral status stated, ""Monitor for dental / oral problems or problems with her eyes or ears and notify the physician as indicated, podiatry consult as needed."" This intervention was not appropriate, because there was no accurate baseline assessment of resident's oral status. She had multiple broken, carious teeth had not been identified on assessment, and there was no evidence that the growth in the roof of her mouth had been assessed. The minimum data set assessment (MDS) nurse (Employee #44) verified, during an interview at 4:30 p.m. on 10/13/10, that no care plan had been developed to accurately describe the care and services needed to address this resident's oral hygiene and/or dental needs. After this issue was identified by the surveyor on 10/13/10, Employee #44 examined the resident's mouth and confirmed the resident had broken teeth and a dark-color upper right tooth. Employee #44 called the resident's daughter, who gave her the name of the dentist the resident had seen in the past. Employee #44 stated the facility would call this dentist to see if he could evaluate the resident here at the facility. There was no evidence in the medical record that the facility had talked to the family about this issue prior to the surveyor's intervention. .",2014-12-01
10729,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,431,E,0,1,H9I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to assure medications were stored safely under proper temperatures and failed to dispose of outdated medications to prevent them from being unsafely administered to residents. These practices were present in two (2) of two (2) medication storage rooms and had the potential to affect more than an isolated number of residents. Facility census: 49. Findings include: a) Observation of the facility's medication rooms, on [DATE] beginning at 10:00 a.m., found the temperatures of the refrigerators used to store medications were not monitored consistently to assure the medications were stored at safe temperatures. This was true for both of the medication storage rooms. The refrigerator in the medication room serving Unit A did not have evidence of temperature monitoring from [DATE] to [DATE]. The temperature of the refrigerator in the medication room serving Units B and C was monitored on only three (3) of twelves (12) days month-to-date in October. The director of nursing (DON), when interviewed on [DATE] at 1:00 p.m., verified the refrigerators' temperature logs were not completed and said it was the facility's practice to record the temperatures on evening shift daily, to make sure medications requiring refrigeration were stored at a proper temperature. - b) Review of the facility's storage of medications in the medication room serving Units B and C, in the company of a licensed practical nurse (LPN - Employee #55 at 10:00 a.m. on [DATE], found multiple medications that were outdated. These medications were as follows: - Magnesium Oxide 400 mg - three (3) bottles with expirations dates of [DATE] - Bacteriostatic Sodium Chloride 30 mg 0.9% 30 ml with an expiration date of [DATE] - Mineral Oil 30 ml containers - seven (7) containers with expiration dates of "",[DATE]"" - Acetaminophen 650 mg rectal suppositories - twenty seven (27) suppositories with expiration dates of "",[DATE]"" - Milk of Magnesia 30 ml containers - seven (7) containers with expiration dates of "",[DATE]"" - Influenzae Virus Vaccine - 5 ml ,[DATE] formula with an expiration date of [DATE] - Heparin 5,000 Units 1 ml container with an expiration date of "",[DATE]"" - Albuterol Sulfate 0.083% Inhalation Solution with an expiration date of "",[DATE]"" - Levaquin 250 mg/ml containers for injection (bags for intravenous administration) with expiration dates of [DATE]. The LPN confirmed these medications did not belong to a specific resident but were stock medications for use by any resident who needed them. - c) The DON was made aware of the outdated medications, and she was asked to review the medications in the medication room serving Unit A at 4:20 p.m. on [DATE]. This medication room also contained multiple outdated medications as follows: - Zinc 50 mg tablets with an expiration date of "",[DATE]"" - Ethezyme debriding ointment with an expiration date of "",[DATE]"". (It was verified that this medication was for a resident who expired on [DATE].) - Aspirin 600 mg rectal suppositories with an expiration date of "",[DATE]"". (It was verified that these were for a resident who expired on [DATE].) - d) During an interview with the DON at 4:15 p.m. on [DATE], she stated the facility did not really have a system to ensure outdated medications were discarded. She provided the facility's policy titled ""Medication Storage in the Facility"" which stated the following: - In paragraph #10: ""Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees to 30 degrees."" - In paragraph #11: ""Medications requiring refrigeration at temperatures between 36 degrees and 46 degrees are kept in a refrigerator with a thermometer to allow temperature monitoring."" Further review of the policy found, in paragraph #13: ""Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy."" The facility failed to follow its policy with respect to monitoring medications requiring refrigeration and disposing of outdated medications. .",2014-12-01
10730,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,371,F,0,1,H9I611,". Based on observation, staff interview, and review of the USDA Food Code, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The practices have the potential to affect all residents who receive nourishment from dietary services. Facility census: 49. Findings include: a) Observation of the automatic dishwasher, on 10/11/10 at 9:40 a.m., found the rinse cycle water temperature reached 208 degrees Fahrenheit (F). The recommended temperature posted on the outside of the machine was 180 degrees F. Review of the dishwasher temperatures log maintained by the facility revealed the rinse cycle water temperature had exceeded 180 degrees F one fifty-three (53) occasions between 10/01/10 and 10/11/10. On 10/11/10 at 10:00 a.m., an interview with the dietary manager (Employee #19) revealed she was unaware that the dishwasher had a maximum rinse cycle water temperature. Review of the USDA Food Code revealed: ""The temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 190 degrees or less than."" Employee #19 and a member of the maintenance department (Employee #124) provided information from Hobart (a service vendor) that the dishwasher's temperature gauge was reading 25 degrees F higher than the internal temperature. The temperature gauge was subsequently replaced on 10/12/10. - b) On 10/13/10 at 10:55 a.m., an observation of the kitchen found cleaning cloths with bleach water on them where on the table where two (2) staff members were preparing parsley for garnishes and where other food preparation was also being done on the table. On 10/14/10 at 9:15 a.m., Employee #19 confirmed that cleaning cloths and solutions should not be on the table when food preparation was occurring. - c) On 10/13/10 at 10:55 a.m., an observation of the kitchen revealed steam table pans that were ready for use had debris inside which could be scraped off with a fingernail, and baking pans had heavy layers of charred food and/or grease debris on their outside surfaces. An interview with Employee #19, on 10/13/10 at 11:30 a.m., confirmed the pans were not clean. .",2014-12-01
10731,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,441,E,0,1,H9I611,". Based on observation and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Observations in the dining room during the evening meal found staff members did not wash their hands upon entering the dining room and/or after handling potentially contaminated items. This practice has the potential to affect more than an isolated number of residents. Facility census: 49. Findings include: a) During the evening meal in the dining area on 10/12/10 at 5:15 p.m., observation found a nursing assistant (NA - Employee #90) assisting a male resident from a Merriwalker to a stationary chair. This NA did not wash her hands before handling milk containers and eating utensils. Also on 10/12/10 at 5:15 p.m., observation found another NA (Employee #70) picking a clothing protector off the floor. She did not wash her hands before handing food containers and food. On 10/12/10 at 5:30 p.m., Employee #60 (NA) handled the trash can in the dining room and did not wash her hands before handling food. An interview with the director of nursing, on 10/12/10 at 5:45 p.m., confirmed these practices were unsanitary. .",2014-12-01
10732,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,323,E,0,1,H9I611,". Part I -- Based on observation, review of the facility's material safety data sheets (MSDS), and staff interview, the facility failed to provide a resident environment as free of accident hazards as is possible, by failing to secure against unauthorized access rooms that contained hazardous chemicals and/or materials. These included rooms containing biohazardous waste, soiled linen, products for resident care, and/or housekeeping chemicals that may be harmful if ingested or if they came into contact with a resident's skin or eyes. This practice had the potential to affect more than a minimal number of residents on the A, B and C units who were cognitively impaired and had the ability to be independently mobile about the floor whether in a wheelchair or on foot. Facility census: 49. Findings include: a) During a random tour of the facility on 10/14/10 at approximately 9:42 a.m., two (2) surveyors observed two (2) doors, to rooms labeled as biohazardous on the B and C units of the facility, were unlocked and accessible to residents. Stored in these rooms were dirty linens from the units, trash from the units, a large red sharps container that could accommodate a resident's hand, and resident care products and housekeeping products, each with the precautionary labels stating ""... hazardous to humans and domestic animals. Causes moderate eye irritation."" Following this observation, a tour of the A wing discovered the door to a janitor's closet was also unlocked and accessible. Inside this closet were stored Clorox Germicidal Bleach, PROFI Floor Cleaner/Oil & Grease Remover, WIWAX Cleaning & Maintenance Emulsion, Purell Instant Hand Sanitizer Foam, Stride Citrus SC (Super Concentrate), GP FORWARD SC (Superconcentrate), VIREX II 256. Review of the MSDS for these products found precautionary statements that, at a minimum, stated the products ""may be mildly irritating to eyes and skin"". The maximum health hazard identification statements for at least two (2) of the products found they were ""corrosive and may cause permanent damage including blindness, corrosive and may cause permanent damage to mouth, throat and stomach"". On 10/13/10 at 10:20 a.m., the facility's administrator (Employee #132) and the person identified as being responsible for assuring the unit's environmental safety (Employee #131) were notified of these findings and asked to make the areas safe. When an additional tour was completed at 10:30 a.m., the doors to the rooms in question had been locked / secured against unauthorized access by residents. -- Part II -- Based on observation, facility policy review, and staff interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control, by failing to maintain hot water temperatures in a safe temperature range to prevent scalding. Water temperatures in the hand sinks in resident restrooms on B and C wings were found to be in excess of 110 degrees Fahrenheit (F), with high temperatures ranging between 118.0 and 121.4 degrees F. This practice had the potential to affect more than an isolated number of residents on the skilled nursing unit. Facility census: 49. Findings include: a) Environmental observations, on 10/14/10 at 10:37 a.m., found the water temperature at the hand sink in the resident restroom on B wing to be 121.1 degrees F. The water temperature at the hand sink to the resident restroom on C wing was found to 120.0 degrees F. Immediately following these observations, hand sinks in random resident rooms on the skilled nursing unit were tested by two (2) surveyors. The temperatures ranged from 118.0 to 121.4 degrees F. Employee #123 accompanied the surveyors to continue checking the water temperatures in other areas where residents had access to the water supply. - According to Table 1 titled ""Time and Temperature Relationship to Serious Burns"" in the Guidance to Surveyors for 483.25(h), found in Appendix PP of the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS): Water temp - Time required for a 3rd degree burn 133?F (56?C) - 15 sec 127?F (52?C) - 1 min 124?F (52?C) - 3 min 120?F (48?C) - 5 min 100?F (37?C) - Safe Temperatures 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 facility policy titled ""Utilities Management Plan - Water Temperature"" found checks of water temperatures were to be made monthly in both the hospital and skilled nursing unit. - During an interview on 10/14/10 at 10:37 a.m., the maintenance man (Employee #123) confirmed that the facility had, in the past, monitored and logged water temperatures on a regular basis; however, due to a change in personnel, this task had not been assigned to be completed anyone else in the facility. .",2014-12-01
10733,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,463,D,0,1,H9I611,". Based on observation and staff interview, the facility failed to assure the nurse call system was working in a room occupied by two (2) of forty (40) Stage I sample residents. Resident identifiers: #2 and #54. Facility census: 49. Findings include: a) Residents #2 and #54 Testing of the nurse call system, during Stage I of the survey on 10/12/10 at 2:00 p.m., found the call system serving the room shared by Residents #2 and #54 did not function properly. When the call lights were activated at bedside, the nurse call system did not respond with a visual or auditory signal. Staff repaired the nurse call system immediately when this matter was brought to their attention on 10/12/10.",2014-12-01
10734,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,334,E,0,1,H9I611,". Based on medical record review, facility policy review, and staff interview, the facility failed, for five (5) of five (5) residents reviewed, to assure the resident or the resident's legal representative was provided information regarding the benefits and potential side effects of influenza immunization prior to the administration of the vaccine. This practice has the potential to affect more than an isolated number of residents in the facility. Resident identifiers: #33, #9, #21, #19, and #14. Facility census: 49. Findings include: a) Residents #33, #9, #21, #19, and #14 When reviewed on 10/13/10 at 2:00 p.m., the facility's influenza / pneumonia vaccine practices for Residents #33, #9, #21, #19, and #14 included no method of informing the resident / responsible party of the benefits and potential side effects of the vaccines. The facility's infection control nurse (Employee #44), when interviewed on 10/13/10 at approximately 2:30 p.m., confirmed the facility did not currently have a method of informing the resident or resident's legal representative of the benefits and potential side effects of influenza immunization prior to administering the vaccine. .",2014-12-01
10735,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,278,D,0,1,H9I611,". Based on observation, record review, and staff interview, the facility failed to assure the dental status of one (1) of twenty-three (23) Stage II sample residents was accurately encoded in the resident's minimum data set (MDS) assessment to reflect the presence of broken, carious teeth. Resident identifier: #33. Facility census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. Review of the resident's most recent MDS, a comprehensive annual assessment with an assessment reference date of 06/06/10, found the assessor noted, in Section L, that the resident had some teeth lost and did not have or use dentures. The items in Section L to identify any broken, loose, or carious teeth was not marked. The MDS nurse (Employee #44), when interviewed at 4:30 p.m. on 10/13/10, verified the resident's annual MDS had been encoded incorrectly with respect to her dental status. The MDS nurse also verified that the monthly nursing summaries completed for at least the past four (4) months did not accurately reflect the resident's dental status. .",2014-12-01
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
10742,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-08-25,166,E,1,0,36XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's grievance / complaint reports, family interview, resident interview, and staff interview, the facility failed to make prompt efforts resolve grievances. There was no evidence of a thorough investigation into grievances filed by (or on behalf of) two (2) of six (6) sampled residents and four (4) random residents identified through a review of twenty-two (22) grievance reports reviewed. Resident identifiers: #136, #7, #158, #106, #24, #31, and #137. Facility census: 154. Findings include: a) Resident #136 Review of grievance / complaint reports found a report filed by a family member dated 07/05/11, stating (quoted as written): ""Daughter reported concerns of the resident in the room next to her mother and her screaming all of the time. ..."" Under the heading ""Documentation of Facility Follow-up"", and in response to the question ""What other action was taken to resolve this concern (be specific)?"", the author wrote: ""Informed (name of family member filing complaint) we were working /c (with) (name of Resident #155) & collaboration /c Admin, DON (director of nursing),Soc Serv & myself."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""... 3) (name of family member filing complaint) was advised of above re (regarding) (name of Resident #155)."" The author also noted she had a one-to-one conversation with the persona filing the complaint about this resolution on 07/08/11. An interview was conducted with the family member on 08/24/11 at 2:00 p.m., she stated the grievance regarding the resident in the next room (#155) was still an issue, that there had been no resolution of this issue, and that the residents in the vicinity of the room of this resident were complaining. According to the family member, this has been an on-going unresolved issued for the past six (6) weeks. In an interview on 08/25/11 at 11:00 a.m., the director of nursing (DON) and the unit manager reported the facility had implemented measures to address Resident #155's screaming, but nothing seems to work. They stated they could not discuss the specific measures with the family member, but they agreed this grievance has not been resolved. This interview also revealed the facility had not conducted any investigation to see whether the noise level associated with Resident #155's screaming was uncomfortable / disruptive to other residents in the vicinity (beyond Resident #136). Although the above note grievance / complaint report was marked to indicate the concern was resolved, it was, in fact, not resolved and present ongoing concerns to Resident #136. -- b) Resident #7 Review of grievance / complaint reports found a report filed by a family member dated 08/05/11, stating this resident was missing two (2) gowns and some white plastic hangers with the resident's name on them. Under the heading ""Documentation of Facility Follow-up"", the unit manager and housekeeping supervisor were identified as the persons designated to take action on this concern. All of the other sections of the form under follow-up were blank. There were no details of what action(s) was (were) taken to resolve the concern. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Facility was searched, laundry staff interviewed. Unable to locate the clothing. Will see if the facility will replace."" There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- c) Resident #158 Review of grievance / complaint reports found a report filed by a family member dated 08/04/11, stating she was missing a pair of pants with small brown checks, a pair of yellow Capri pants, and a pullover sweater with short sleeves. Under the heading ""Documentation of Facility Follow-up"", the housekeeping supervisor was identified as the person assigned to take action on this concern on 08/05/11, and the concern was to be resolved by 08/12/11. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Facility was searched, unable to locate missing items. Will see if the facility will replace."" There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- d) Resident #106 Review of grievance / complaint reports found a report filed by the resident dated 07/27/11, stating: ""She stated she does (symbol for 'not') get her things back from laundry. When they bring her clothes back, they just put them anywhere. Other peoples clothes are put in different closets."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""Had a new girl working in laundry and she was putting the clothes in the wrong closets other laundry aids sorting them out. This documentation provided an explanation as to what happened, but there was no indication as to whether the facility actually found the resident's missing clothes. -- e) Resident #24 Review of grievance / complaint reports found a report filed by a family member dated 07/06/11, stating a cup containing six (6) rings (""good costume jewelry"") at her bedside that missing since 07/01/11. Under the heading ""Documentation of Facility Follow-up"", no individual staff member had been designated as responsible for taking action on this concern; instead, the author of the report noted (quoted as written): ""Asked Staff to watch for these Items."" The date this action was assigned was 07/06/11, and the date to be resoled was 07/07/11. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Rings have (symbol for 'not') been located."" During an interview with Resident #24 on 08/25/11 at 2:00 p.m., she stated they never did find her rings. She stated she knew she put them in a cup on her bedside table before she went to sleep. When asked if the facility ever got back with her about the rings, she said she had never heard anything since she reported them missing. -- f) Resident #31 Review of grievance / complaint reports found a report filed by the resident dated 06/09/11, stating she was missing a black hoodie. Under the heading ""Documentation of Facility Follow-up"", the unit manager and ""ESD"" (environmental services director) were identified as the persons designated to take action on this concern, with the concern assigned on 06/09/11 and the date to be resolved identified as 06/16/11. In response to the question ""What other action was taken to resolve this concern (be specific)?"", the author wrote: ""Checked with laundry."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""Facility was searched, unable to locate hoodie. Will see if facility will replace."" There was no evidence to reflect the resident was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing item. -- g) Resident #137 During an interview with Resident #137, he informed this surveyor that he was not able to find his Kindle (brand-name of a wireless electronic reading device or ""E-reader""). He stated it has been missing since 08/11/11; he reported the missing E-reader to staff a couple weeks ago, but staff still hasn't found it. He stated he fell asleep and he had it in his bed. When he woke up, they changed his sheets, and he thought that maybe it got wrapped up in his sheets. He stated he has checked with the laundry, and they have not found it. He stated he called the police today (08/24/11) and reported it. Resident #137 stated the device cost him over a hundred dollars and he had about fifty (50) books on it that he had bought. He had the two (2) nursing assistants on duty that night to look for it. He stated another nursing assistant came in at shift change, and he helped look. The nursing assistants were aware of the missing electronic device, but they did not report it to the nurse to pursue an investigation. - Review of the facility's grievance / complaint reports for the past three (3) months found no report recording the resident's complaint regarding the missing E-reader. The administrator was questioned about this at 4:15 p.m. on 08/24/11. He stated he would ask the nurses on the unit if they had the complaint form, because they are the ones who do them. On 08/25/11, a copy was provided of a grievance / complaint report dated 08/15/11, which recorded the following concern (quoted as written): ""Reports Loss of E-Reader the last of last wk."" Under the heading ""Documentation of Facility Follow-up"", ""All Departments"" were identified as the persons designated to take action on this concern, with the concern assigned on 08/15/11 and the date to be resolved identified as 08/26/11. In response to the question ""What other action was taken to resolve this concern (be specific)?"", the author noted (quoted as written): ""Questioned (name of resident) if he could have left this somewhere out of Facility. He reports was out of case laying in his room - when he last saw it."" The author also noted all departments were notified, all second floor staff was notified and all department managers were to be notified in the morning. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""No"" and wrote: ""Unable to find missing E-Reader. 8/24 - (Name of resident) filed a report /c (with) Hunt. ([MEDICAL CONDITION]) Police Dept."" There was no written investigation, nor were statements obtained from staff about the missing E-reader. The information the resident reported to this surveyor (about the device being in his bed when he last saw it and then being gone when he woke up), which he had also told the nursing assistants the night the device went missing, was not included in the grievance / complaint report. During an interview with Employee #157 (a nursing assistant) on 08/24/11 at 5:30 p.m., he said he looked for the device and verified the resident reported it missing on 08/11/11. When asked to whom he had reported the resident's complaint about the missing device, he said everyone knew about it and all of the nurses knew. He stated he has picked things up out of the resident's trash can beside his bed many times, where he drops items, and he thinks he may have dropped it in the trash. Employee #175 verified that, when the resident reported this missing, he said had it in bed with him at that time. The administrator, when subsequently interviewed about the facility's practice of replacing missing items, stated that sometimes they do if the family buys something new; they just bring in a receipt. He said that, if the residents have the missing items on their inventory lists, he will replace them, but they do not replace everything that comes up missing. He was not sure if they kept records of what they replaced and the reasons why they chose not to replace certain items. There was no records of these actions provided to the surveyor at the conclusion of this survey on 08/25/11. .",2014-12-01
10743,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-08-25,258,E,1,0,36XK11,". Based on observation, review of complaint files, family interview, resident interview, confidential staff interview, and staff interview, the facility failed to provide for the maintenance of comfortable sound levels for residents who were disturbed by another resident's yelling. This affected more than an isolated number of residents. Resident identifiers: #136, #48, #106, and #45. Facility census: 154. Findings include: a) Review of complaint files revealed a complaint by Resident #136's medical power of attorney representative (MPOA), dated 07/05/11, about ""concerns of the resident in the room next to her mother and her screaming all of the time"". Further review of this complaint revealed the ""resolution"" was to inform the MPOA that the administrator, director of nursing (DON), social services, and the nurse manager were collaborating and working with the resident who was yelling out (Resident #155). -- b) Resident #136 During an interview with Resident #136's MPOA on 08/24/11 at approximately 2:30 p.m., she said she met with the nurse manager and the DON about Resident #155's yelling, but there has been no improvement or resolution. She said if someone sits with Resident #155, she doesn't yell. Resident #136 agreed that Resident #155 yells ""all the time"". - Observation from within Resident #136's room with the door closed, on 08/24/11 from 2:50 p.m. to 2:54 p.m., found Resident #155 yelled audibly forty-one (41) times; from 3:03 to 3:08 p.m. she yelled audibly thirty-seven (37) times. Observations made periodically on 08/24/11 and 08/25/11 found this to be a frequent behavior. -- c) Resident #48 During an interview with Resident #48 on 08/24/11 at 3:30 p.m., he stated Resident #155, who is two (2) doors down, yells a lot and ""keeps everybody awake"". He said the yelling awakens him five (5) to six (6) nights per week and, as a result, he feels tired the next day; she yells during the day, but it is worse at night. He stated he complained to one (1) of the nursing assistants, spoke to someone in the office, and spoke with the administrator about the yelling. He stated he has also shut Resident #155's door but can still hear her with the door closed. He stated she quiets when staff enter her room, but she resumes yelling as soon as they leave. -- e) Resident #106 During an interview with Resident #106 on 08/24/11 at 3:40 p.m., she stated, ""The lady down the hall hollers day and night (pointing to the short hall where Resident #155 resides) ... I don't get no rest here at night."" She said she spoke with the nurse manager and allegedly was told there is nothing they can do. -- f) Resident #45 During an interview with Resident #45 on 08/24/11 at 3:45 p.m., she stated the lady down the hall yelling (gesturing in the direction of the short hall where Resident #155 resides) awakens her five (5) or six (6) nights per week and, as a result, she feels groggy the next day. When asked if she thought she would sleep better if it were quieter, she said, ""I know I would"". -- g) During interview with a licensed practical nurse (LPN - Employee #39) on 08/24/11 at 4:05 p.m., she said that Resident #136's MPOA, and Residents #18, #42, and #48 have all complained of Resident #155 yelling, although none, to her knowledge, had filed a formal grievance. She agreed that Resident #155 seemed to cycle, noting she may yell a lot for several days, then seems to wear herself out and sleeps. -- h) A confidential interview with a nursing assistant revealed Resident #155 screams out often and staff sees about her comfort; Resident #136 complains about the noise, Resident #48 will come find staff when she's yelling, and Resident #26 will ask who is yelling. A confidential interview with another nursing assistant revealed that talking to Resident #155 helps, but she starts yelling again as soon as staff leave the room. -- i) During an interview with the DON, the unit manager, and the social worker (Employee #169) on 08/25/11 at 11:50 a.m., they reported having tried numerous interventions for Resident #155 to try to ensure her needs are met. The resident's son is aware she yells and disrupts others, they have consulted with a dementia specialist, and the physician is aware that she is disruptive. They acknowledged that Resident #136's MPOA filed a grievance about Resident #155 ""screaming all of the time"" on 07/05/11 and is not yet satisfied. They said all acknowledged that commonsense would tell you that other residents are hearing Resident #155, but none of the other residents have complained to them. .",2014-12-01
10744,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-08-25,280,D,1,0,36XK11,". Based on record review, family interview, and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents after it was made known that the female resident and/or her medical power of attorney representative (MPOA) did not want a male staff member performing catheterizations on the resident. Resident identifier: #136. Facility census: 154. Findings include: a) Resident #136 Record review of a nursing progress note, dated 08/21/11, revealed the MPOA for Resident #136 ""keeps insisting"" the resident does not want a male staff member performing catheterizations on her, although the resident herself did not such voice complaints. During an interview on 08/24/11 at approximately 2:30 p.m., Resident #136's MPOA stated the resident was catheterized once over the past weekend by a male nurse (Employee #46), and the resident allegedly cried because she did not want a male to perform the catheterization. The MPOA reported that Resident #136 requires a catheterization three (3) times daily (once each shift) to relieve residual urine, and her nephrologist advised against having a permanent indwelling catheter inserted. During an interview with a licensed social worker (LSW - Employee #169) on 08/24/11 at 11:20 a.m., she said no one had reported to her about Employee #46 catheterizing the resident against the resident's (or the MPOA's) wishes, nor had she received a request for a female nurse to perform the procedure instead of a male. Review of the resident's care plan revealed no revision to the interventions in acknowledgement of the MPOA and/or the resident's request to have only a female nurse perform catheterizations. Interview with the director of nursing and a nurse manager, on 08/25/11 at approximately 11:50 a.m., revealed they were unaware that Resident #136 and/or her MPOA did not want a male to perform catheterizations.",2014-12-01
10745,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-08-31,155,D,1,0,H3XI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the advance directives of one (1) of six (6) sampled residents were honored by the facility. Resident #94's expressed her wishes with respect to advance directives in writing prior to losing the capacity to make her own informed medical decisions. The facility permitted the resident's medical power of attorney representative (MPOA) to change these written instructions for end-of-life care after the resident was no longer able to express her wishes. Facility census: 93. Findings include: a) Resident #94 A review of Resident #94's closed medical record revealed she was admitted to the facility on [DATE]. On 05/08/11, the physician determined she possessed the capacity to make her own informed health care decisions. Further record review disclosed a combined WV Advance Directive / Living Will / Medical Power of Attorney document, which had been completed and signed by Resident #94 on 03/13/07. This form contained the following: ""If I should reach a point when I lack capacity to make medical decisions, am in a terminal state, or become permanently unconscious or remain in a permanent vegetative state I have indicated my wishes by my initials on the lines below."" In the section of the document labeled Living Will, the resident indicated she did not want life prolonging treatment and wished to be permitted to die naturally with only the administration of any medication or the performance of any medical treatment deemed necessary to alleviate pain. Regarding the administration of artificial nourishment, the resident stated, ""I do not want artificially provided water or other artificially provided nourishment or fluids (tube feedings intravenous fluids etc)."" The form had an area labeled ""Special Directions or Limitations"", in which the resident indicated she wanted to be kept comfortable and was to be a DNR (do not resuscitate). In the section designating a medical power of attorney representative, the resident identified her daughter as the person to ""make health care decisions for me, in accordance with this directive, when I no longer have decisional capacity and cannot communicate my healthcare wishes."" The resident was discharged to home on 06/02/11. She was then readmitted to this facility on 06/30/11, after she had a fall at home resulting in a hospitalization . When the resident was readmitted , her previous advance directives remained unchanged. On 06/30/11, the physician subsequently determined she no longer possessed the capacity to understand and make her own health care decisions capacity to make her own decisions. On 07/01/11, the resident's MPOA came to the facility and changed her code status to a ""Resuscitate"", which was contrary to the wishes the resident specifically stated in her advance directives. The administrator and director of nursing were made aware of this finding at 10:30 a.m. on 08/31/11. The administrator contacted by telephone the nurse who changed this resident's code status to a ""Resuscitate"". The administrator then related that the resident's MPOA requested the change, so the nurse completed a new form.",2014-12-01
10746,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2009-07-22,280,D,0,1,UHKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to revise the care plans for two (2) of twenty-five (25) Stage II sampled residents. Two (2) residents, who recently had a significant weight loss, did not have their care plans revised to reflect the current interventions staff was implementing to monitor weight and prevent a further decline. Resident identifiers: #120 and #133. Facility census: 122. Findings include: a) Resident #120 Resident #120's medical record, when reviewed on 07/22/09 at 9:00 a.m., disclosed a [AGE] year old male who was admitted to the facility on [DATE]. The medical record stated the resident's admission weight, on 02/26/09, was 169 pounds. The resident's weight, on 07/18/09, was reported to be 154 pounds. The resident had a significant weight loss of 8.8 % in a four (4) month period of time. The resident's current care plan, with a revision date of 06/04/09, did not include all current interventions the facility staff was implementing to prevent further weight loss. The dietary manager (Employee #12), when interviewed on 07/22/09 at 11:00 a.m., reported the facility staff was implementing interventions to monitor the resident's weight and prevent a further decline. The dietary manager reviewed the current care plan (with a revision date of 06/04/09) and confirmed all current interventions were not listed on the current care plan. The care plan nurse (Employee #32), when interviewed on 07/22/09 at 2:00 p.m., reviewed the resident's current plan of care (with a revision date of 06/04/09) and confirmed the resident's current care plan was not revised to include all current interventions the staff was implementing to improve weight and prevent further decline. b) Resident #133 Resident #133's medical record, when reviewed on 07/22/09 at 10:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident's medical record stated the resident's weight, on 04/04/09, was 128 pounds. The resident's weight, on 07/09/09, was reported to be 116 pounds. The resident had a significant weight loss of 9.3 % in a three (3) month period of time. The resident's current care plan, with a revision date of 07/01/09, did not address all current interventions the facility staff has implemented to address weight loss and prevent further decline. The dietary manager (Employee #12), when interviewed on 07/22/09 at 11:00 a.m., reported the facility staff was implementing interventions to monitor the resident's weight and prevent further decline. The dietary manager reviewed the current care plan (with a revision date of 07/01/09) and confirmed current interventions staff were implementing to restore weight was not addressed on the care plan. The care plan nurse (Employee #32), when interviewed on 07/22/09 at 2:00 p.m., confirmed the resident's current plan of care (with a revision date of 07/01/09) did not address weight loss and did not include all current interventions the staff was implementing to improve the resident's weight, and prevent further decline. .",2014-12-01
10747,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2009-07-22,311,D,0,1,UHKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record review, staff interview, and resident interview, the facility did not ensure that one (1) resident of a sample of twenty-five (25) received care and services to maintain or enhance the resident's ability to ambulate. Resident #80 had a physician's orders [REDACTED]. Facility census: 122. Findings include: a) Resident #80 An interview with Resident #80, on 07/22/09 at 9:30 a.m., revealed the resident wanted the nursing assistants to assist her with ambulation. The resident stated, ""The aides used to walk me, but they don't do it any more. I want to walk out in the hall, and they don't take me any more for my walk, and I need someone with me."" An interview with the assessment coordinator (Employee #32), on 07/14/09 at 10:10 a.m., revealed the resident had an order to ambulate with a wheeled walker daily. She stated that, after talking with the nursing assistants, this morning they were not walking the resident every day. She was starting the resident on a walk-to-dine program that would require the nursing staff to walk the resident to the dining room for meals on a daily basis. Record review revealed a physician's orders [REDACTED]."" A review of the facility's Resident Flow Record revealed the documentation was not accurate for the resident's ambulation. The nursing assistants were marking the area for ambulation with the word ""up"". An interview with a registered nurse (Employee #36), on 07/14/09 at 10:30 a.m., revealed the documentation for the resident's ambulation was not clear as to what was happening with the resident concerning her daily ambulation. She was uncertain as to how the nursing assistants were documenting. The form revealed that each day the nursing assistants were marking ""up"", and the RN did not have an explanation for the documentation. An interview with a licensed practical nurse (Employee #40), on 07/22/09 at 11:30 a.m., revealed a treatment aide usually ambulated the residents on the 3:00 p.m. to 11:00 p.m. shift. She also stated that, if Resident #80 stated she was not being walked by the staff, this was probably correct. She further stated the resident was alert and would know that she was not being walked. Observations of the resident, in the dining room on 07/22/09 at 9:30 a.m., found the resident seated in a wheelchair. The resident's wheeled walker was not in the dining room. An interview with the director of nursing (Employee #2), on 07/22/09 at 2:00 p.m., revealed the nursing assistants were not correctly documenting the resident's ambulation daily. She related that, when she asked the nursing assistants why they were documenting the word ""up"" on the flow sheet, they told her if someone needed assistance with ambulation they wrote ""up"". She indicated she would need to do some education with the nursing assistants. She further stated she believed they were ambulating the resident. .",2014-12-01
10748,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2009-07-22,492,C,0,1,UHKM11,"Based on observation, facility records, and staff interview, the facility failed to post the nurse staffing as required by Section 941 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which requires skilled nursing facilities and nursing facilities to post daily for each shift the number of registered nurses, licensed practical nurses, and unlicensed nursing staff directly responsible for resident care in the facility. This had the potential to affect all residents. Facility census: 122. Findings include: a) During the general tour at 1:00 p.m. on 07/20/09, observation revealed the nursing staffing posting contained only the number of licensed and unlicensed staff and total full-time equivalents (FTEs) for each shift. The posting failed to differentiate the categories of nursing staff by differentiating between licensed practical nurses and registered nurses. During an interview with the administrator and the director of nurses at 4:00 p.m. on 07/22/09, this lack of information was pointed out and they were given the source of the requirement.",2014-12-01
10749,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2009-07-22,371,E,0,1,UHKM11,"Based on observation and staff interview, the facility failed to assure all kitchens contained hands-free garbage disposal equipment for dietary employee use at hand-washing stations. This was evident for one (1) of the two (2) kitchens and had the potential to affect all residents on the 500 Hall who receive nourishment from that kitchen. Facility census: 122. Findings include: a) During the initial tour on 07/20/09, an attempt to discard a used paper towel revealed the step-on trash can at the employee handwashing station in Kitchen #2 was not functioning. A dietary staff member (Employee #180) directed the surveyor to throw her paper towel onto a tray of food that she was going to discard. On 07/21/09 at 11:30 a.m., observation of Kitchen #2 revealed no trash receptacle at the employee handwashing station. Further observation of Kitchen #2 found a large black, round plastic trash can with a fitted lid in the dishwashing area. There were no other trash receptacles in the kitchen. On 07/22/09 at 4:00 p.m., a repeat observation of Kitchen #2 again found no trash receptacle at the employee hand-washing station. This surveyor reported the observation to Employee #12, and she explained that the step-on trash can broke yesterday. She threw her paper towel into the large black, round plastic trash can with a fitted lid that was housed in the dishwashing area. This surveyor did the same but could not avoid touching the trash can with her hand as she disposed of a used paper towel. .",2014-12-01
10750,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,279,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. The staff caring for this resident was not aware she had a drug-resistant infection in her eyes and nares. There was no evidence that the facility had a plan to alert staff and visitors of special precautions needed with respect to having contact with the resident's body secretions. This affected one (1) of thirteen (13) sampled residents . Resident identifier: #32. Facility census: 75. Findings include: a) Resident #32 Review of Resident #32's medical record revealed she was admitted to the hospital on [DATE], for an altered level of consciousness. According to her hospital records, she had had a fever and drainage from her eyes, and she tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her right eye and her nares. She was receiving antibiotics for her nares and her eyes and was still receiving this treatment when she came back to the nursing home. Observation of this resident revealed she was not in any type of isolation, and her care plan did not identify any special precautions to be taken when interacting with or caring for this resident. During an interview with the infection control nurse (Employee #26) on 06/24/09 at 3:00 p.m., she was made aware of the resident's infections. She confirmed this was missed when the resident returned from the hospital; the resident's infections were not record on the facility's infection control log, and no isolation precautions were initiated when she returned from the hospital. She also confirmed Resident #23 should have been placed in isolation. This resident's room was observed at 9:00 a.m. on 06/25/09. The nursing assistant was observed taking special precautions prior to entering the room to care for this resident. There was a sign placed on the door to see the nurse before entering the room. These precautions were not put into place until seven (7) days after the resident had returned from the hospital. .",2014-12-01
10751,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,328,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #72 received the proper respiratory care and treatment. Staff failed to utilize proper technique to administer a nebulizer treatment to a resident with a [MEDICAL CONDITION] (trach). Staff also did not ensure this resident's oxygen was administered in accordance with physician's orders [REDACTED]. Proper respiratory care and treatment was not provided for one (1) of thirteen (13) sampled residents. Resident identifier: #72. Facility census: 75. Findings include: a) Resident #72 1. During an observation of the medication administration for Resident #72 on 06/23/09, this resident was observed to have an order for [REDACTED].# 81) administered this treatment by holding a face mask over the resident's trach. Observation found the medicated aerosol coming out the sides of the mask, with very little actually going into [MEDICAL CONDITION]. The nurse, when questioned about the use of this mask, stated they have special tubing for the trach, but they were out and did not have the right ones available. The assistant director of nursing (ADON), when interviewed on 06/23/09, was asked to provide the facility's policy and procedure for administering a nebulizer treatment to a resident with a trach. The ADON provided a policy for administering hand-held nebulizer treatments but stated they did not have a policy for administering a nebulizer via a trach. The ADON reported they have a respiratory person who comes in and provides them with the equipment they need and shows them how to use it. She stated the facility does have special tubing and [MEDICAL CONDITION] to use for the residents with trachs. 2. Further observations of this resident, throughout the day on 06/23/09 and 06/24/09, revealed this resident did not use her oxygen during those days. The resident's O2 saturation, when checked, was at 98%. A review of the resident's medical record revealed [REDACTED].@ (at) four (4) liters per minute via [MEDICAL CONDITION] Mask Q (every) shift."" The nurse, when questioned about this ordered intervention, reported the resident did not like to wear it. There was no evidence in the resident's record to show the resident's refusal to use the oxygen as ordered had been addressed with the physician prior to this, and there was no evidence to show staff provided teaching regarding the importance of using her oxygen as ordered. A physician's orders [REDACTED]. 3. Observation of this resident's respiratory equipment found a suction machine on her night stand that was very dirty and had the plastic cover broken off of the gauge. The nurse (Employee #81) was made aware of this, and the machine was immediately replaced. .",2014-12-01
10752,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,333,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were free from significant medication errors. The nurse was preparing to administer 60 mg of the anticoagulant medication [MEDICATION NAME], instead of the 45 mg dose ordered by the physician. Receiving too much of this medication could result in internal hemorrhaging. Significant medication errors were found for one (1) of ten (10) residents observed during medication pass. Resident identifier: #66. Facility census: 75. Finding include: a) Resident #66 During medication administration, observation found a nurse (Employee #81) preparing medications for Resident #66. Review of the labels found a pre-filled syringe of [MEDICATION NAME] 60 mg /0.6 ml. The directions on the medication label stated to administer 0.5 ml (50 mg) sub-Q ( subcutaneously) bid (twice a day). While the nurse was preparing her medications, surveyor observed Resident #66's Medication Administration Record [REDACTED]."" The nurse was observed to complete her preparation. As she was preparing to administer the medications to the resident, the surveyor intervened and asked the nurse to stop and double check the label against the MAR. The nurse then verified the dose she was preparing to administer was not correct. The nurse then calculated the correct dose and wasted the excess medication that was in the syringe. The nurse proceeded to tell the surveyor they had discussed this, but the [MEDICATION NAME] did not come from the pharmacy in the dose ordered. .",2014-12-01
10753,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,441,F,0,1,667111,"Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interview, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not periodically reviewed and revised to reflect changes in standards of practice, and the existing procedures were not consistently implemented to prevent the spread of infectious organisms. The facility's did not maintain a record of all residents with infections, including the infectious organism found and/or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased, but there was no evidence to show the facility investigated this increase in nosocomial infections for the causative factors or implemented measures to prevent further incidents of residents contracting nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring an infection. Facility census: 75. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not thorough and were not consistently implemented. The infection control policy (which did not contain an effective date) stated the purpose of the policy was to ensure the infection control program was effective for investigating, controlling, and preventing infections in order to provide a safe sanitary, and comfortable environment. The procedure for this stated the following: ""1. LPN (Licensed Practical Nurse) on duty will report any signs / symptoms of infection to the physician. Along with any other information requested. ""2. Obtain order for treatment. Check ER (emergency) box to see if medication ordered can be obtained. If not STAT medication to facility. ""3. Notify the responsible party of resident's condition and what is being done. ""4. Monitor resident frequently at least each shift for three (3) days. Report any change in condition to the physician and the POA (power of attorney). ""5. The Infection Contort nurse completes a monthly tracking and report sheet."" This was the entire policy on infection control. There was no evidence the facility's infection control program was periodically reviewed or revised to reflect current, nationally recognized standards of practice established by the Centers for Disease Control and Prevention (CDC) and/or the Association for Professionals in Infection Control and Epidemiology (APIC). The facility's policies did not include measures to assure the cause of an infection was investigated and appropriate transmission-based precautions were implemented to control the spread of the infectious organism. A review of the facility's isolation practices revealed the existing policies and procedures were not consistently implemented. (See also citation at F442.) For example: - Resident #32 returned from the hospital with methicillin-resistant Staphylococcus aureus (MRSA) in her eyes and nares. This resident was not added to the infection control log for tracking, analysis, and trending. She was not placed in any form of isolation, and precautions to prevent the spread of this infectious organism to others were not implemented. - Resident #26 was in isolation, and the sign on his door stated ""strict isolation"". This resident had MRSA in a wound on his heel, and the infectious wound drainage was contained in a dressing. The facility was serving his meals on paper plates utilizing disposable dinnerware and keeping his door closed, when the resident only required contact precautions. The facility's policies concerning the types of precautions to be used were unclear. The policy for contact precautions stated these precautions shall be used in addition to standard precautions for residents with specific infections that can be transmitted by direct and indirect contact. This policy indicated gloves should be worn when entering the room. Further review of the policies indicated standard precautions were to be used in the care of all residents, including residents with MRSA. According to the facility's policy, ""Isolation of residents with MRSA in long term care facility's (i.e. contact precautions) is generally not necessary."" During this survey, observation found residents were required to keep the corridor door shut with a sign on the door announcing strict isolation, and nursing assistants and housekeeping staff were directed to wear personal protective equipment (including gloves, masks, and gowns) even if they were not going to come in contact with the resident. According to facility policy, isolation trash and linen were to be handled in the same manner as all trash and linen in the facility, yet there were two (2) very large barrels in the room of one (1) resident in isolation for the containment of trash and linens due to this resident having MRSA. A review of the facility's infection control surveillance data found that, in the month of April 2009, there were ten (10) nosocomial infections in the facility on three (3) halls. In the month of May 2009, there were eighteen (18) residents with nosocomial infections on the 100 and 200 halls, and no data were available regarding residents on the 300 hall. The facility's total census at the time of this survey was seventy five (75). With eighteen (18) affected residents, twenty-four percent (24%) of the facility's census had nosocomial infections. These surveillance data were recorded on the infection control logs, but there was no evidence the facility investigated the cause of these infections (examples: possible transmission during wound care, catheter care, perineal care, the administration of eye drops, etc.). The assistant director of nursing (ADON - Employee #46), when interviewed about the facility's infection control program on the afternoon of 06/24/09, confirmed that what was provided to the survey team was all that was written. When questioned about the facility's isolation policies, the ADON acknowledged not knowing that Resident #32 had a MRSA infection and confirmed that isolation procedures were not always implemented as written. She stated they call the doctor and then do what the doctor tells them to do as far as isolation. .",2014-12-01
10754,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,226,C,0,1,667111,"Based on a review of the facility's policy titled ""reporting abuse"" and staff interview, the facility failed to ensure its ""reporting abuse"" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled ""reporting abuse"" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. .",2014-12-01
10755,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,152,E,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10756,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,465,F,0,1,667111,"Based on observation and staff interview, the facility failed to maintain an environment for residents that was in good repair. All but one (1) hallway had doors in need of repair, the surface of an isolation table was unclean and in poor repair, and Resident #58's room and nursing equipment were not maintained in a sanitary manner. Facility census: 75. Findings include: a) On 06/25/09 at approximately 10:00 a.m., a tour of the inside of the building revealed the corridor doors of resident rooms were scarred and had some type of substance on them. The administrator said the doors had holes that had been filled (but not finished), and the filler was the substance that had been noted. He agreed the doors were not in good condition and commented that they were replacing the doors one (1) at a time, and he hoped to have all of them replaced soon. b) An isolation table was also observed to be in poor repair on the 200 hallway. The table was beaten and scratched up and appeared dirty. c) Resident #58 Observation, during a tour of the facility on 06/25/09, revealed Resident #58's room contained a suction machine that was not clean. The wall area in this room was also dirty, with splashes that ran down the wall. d) On 06/25/09 at approximately 1:00 p.m., the administrator indicated he was unaware of the dirty equipment and condition of the walls in Resident #58's room as well as the soiled table on the 200 hallway. The administrator indicated the areas and equipment would be cleaned as soon as possible. .",2014-12-01
10757,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,309,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents received medication in an amount as ordered by the treating physician. Resident identifier: #21. Facility census: 75. Findings include: a) Resident #21 During observations of the medication administration pass on 06/23/09 at 8:50 a.m., the nurse was monitored while preparing Resident #21's medications. The nurse was noted to place a [MEDICATION NAME] 325 mg (Iron) tablet into a plastic medication administration cup with her other medications. Review of the Medication Administration Record [REDACTED]. As the nurse locked her cart and prepared to enter the resident's room, she was asked to review the MAR. She agreed the resident should not be administered the [MEDICATION NAME] and discarded the medication. .",2014-12-01
10758,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,371,F,0,1,667111,"Based on observations and staff interview, the facility failed to ensure proper sanitation procedures were employed for manual warewashing, freezer units had internal thermometers to ensure food items were being stored at proper temperatures, and food (ice) was being handled with clean utensils when served. These practices have the potential to affect all residents, as all residents who consume food by oral means are served from this central location. Facility census: 75. Findings include: a) During the initial tour of the kitchen on the afternoon of 06/23/09, observation found the walk-in freezer did not contain an internal thermometer to ensure correct temperature levels were being maintained for safe storage of frozen foods. b) Also during the tour, observation found dietary staff had placed a sanitizer tablet in the water of the three-compartment sink for manual warewashing; the tablet had not dissolved. The surveyor questioned staff about the method used to sanitize, and the dietary staff indicated they used tablets that would dissolve in the water to the make the right concentration of sanitizer. Review of the manufacturer's directions for use of the tablets revealed staff needed to increase the amount of water in the sanitizing compartment of the three-compartment sink and use hot water to dissolve the tablets. The dietary manager and the consultant dietitian were present and instructed the staff member to add more water and use two (2) tablets, not one (1). Additionally, they directed the staff member to use hot water, not just warm water from the tap. c) During observations of the medication pass on 06/23/09 at 9:35 a.m., the nurse was observed to pour water (for a resident to take medications) from a clear plastic pitcher. Observation of the water pitcher noted the inner rim beneath the pitcher was coated with a black layer of grime. This same substance was present on the inner portion of the plastic handle. The nurse agreed the pitcher was not clean and stated she had not noticed it. She obtained a clean pitcher to complete her medication pass. .",2014-12-01
10759,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,492,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and review of the West Virginia Health Care Decisions Act, the facility failed to ensure the physician orders [REDACTED]. Resident identifiers: #26 and #77. Facility census: 75. Findings include: a) Resident #26 Review of the medical record found a POST form completed on [DATE]. Section A was documented the resident was to receive cardiopulmonary resuscitation (CPR) should he suffer cardiac or [MEDICAL CONDITION] arrest. Further review noted Section B directed the resident receive comfort measures. This section specifically states: ""Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location."" The two (2) sections, as completed, conflicted with the resident's wishes to receive treatment to support cardiac and [MEDICAL CONDITION] function. The POST form did not comply with the West Virginia Health Care Decisions Act [DATE](b) which states, ""...in accordance with that person's wishes..."". b) Resident #77 The medical record of this female resident contained a POST form dated ""2/ /09"" (date was incomplete), which was not signed by either the resident or the resident's legal surrogate for health care decisions. This was discussed with the office manager on the afternoon of [DATE], who verified the form was incomplete and that there was not way to determine whether the directives otherwise noted on the form reflected the actual wishes of the resident. .",2014-12-01
10760,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,161,E,0,1,667112,"Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. .",2014-12-01
10761,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,225,E,0,1,667112,"Based on a review of the facility's reported abuse investigations and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. Resident #78's family reported the resident had arrived at 2:00 p.m. on 08/22/09, and they reported to the nurse at 6:00 p.m. that no staff member had been in her room since she arrived. The report also stated an indwelling Foley urinary catheter bag had been put in the bed with the resident. During the investigation, a written statement by the nursing assistant providing care for the resident on 08/22/09 indicated the family told her a ""shake"" was also thrown in the corner of the sink and not given to the resident. A review of the investigation into allegations of neglect involving this resident revealed no evidence to reflect the allegations related to the nutritional supplement not being given and the Foley catheter bag laying in the resident's bed were further investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. Resident identifier: #78. Facility census: 77. Finding include: a) Resident #78 According to the facility's abuse reporting records, on 08/22/09, Resident #78's son came to the nurse and wanted to see the charge nurse. That nurse told him she was the charge nurse, and he asked her to come in the resident's room. When the nurse went in the room, he told her his mother (Resident #78) had arrived at the facility at 2:00 p.m. that day, and no staff member had turned her since she arrived and that a Foley catheter bag had been put in bed with the resident. This was at 6:00 p.m. on 08/22/09, and he wanted to make sure this did not happen again. This incident was reported to the State agencies including the nurse aide registry for the nursing assistant responsible for providing care to the resident at that time. A review of the facility's investigation found the family member told the nursing assistant there was a ""shake"" (nutritional supplement) for 2:00 p.m. that was ""thrown"" in the corner of the sink and not given to the resident. In this nursing assistant's written statement, she said she started her shift at 2:30 p.m. that day. There was no evidence the facility interviewed the caregiver who was there at 2:00 p.m. on 08/22/09, to investigated the allegations of the nutritional supplement not being given and the the Foley catheter bag laying on the resident's bed. The five-day follow-up report stated the nursing assistant had been retrained and inserviced on turning and repositioning of the resident, related to the allegation of not having turned her, but there was no evidence the other allegations (related to the nutritional supplement and the Foley catheter bag) were investigated. During an interview on 09/09/09 at 11:00 a.m., the social worker confirmed that not all of the allegations of neglect made by Resident #78's son were thoroughly investigated. .",2014-12-01
10762,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,508,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain radiology services in a timely manner as ordered by the treating physician for one (1) of thirteen (13) sampled residents. Resident identifier: #60. Facility census: 75. Findings include: a) Resident #60 Review of the medical record found a 02/19/09 physician's orders [REDACTED].-resistant Staphylococcus aureus (MRSA) had cleared. Review of the medical record found no evidence the facility had obtained the ordered radiology service for this resident. The director of nursing (DON) provided information which stated the CT would have been scheduled on 03/03/09. During an interview conducted on 06/25/09 at 9:15 a.m., the DON agreed staff should have either obtained the CT scan or called the physician. .",2014-12-01
10763,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-09-10,332,E,0,1,667112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and a review of the manufacturer's instructions for administration, the facility failed to assure it was free of medication error rates of greater than 5%. The facility had a medication error rate of 12.5 %. Medications not administered in accordance with the physician's orders [REDACTED]. Additionally, a nurse prepared to administer the incorrect vitamins, and a resident was not instructed to rinse his mouth out with water following the administration of the [MEDICATION NAME] Diskus. There were forty (40) opportunities with a total of five (5) medication errors observed. Resident identifiers: #75, #6, #63, and #47. Facility census: 77. Findings include: a) Resident #75 During the medication pass observation on 09/09 2009 at 9:00 a.m., the nurse (Employee #15) administered medications to Resident #75, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. b) Resident #6 During the medication pass observation on 09/09 2009 at 9:15 a.m., Employee #15 administered medications to Resident #6, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. c) Resident #63 During the medication pass observation on 09/09/09 at 9:20 a.m., the nurse administered medications to Resident #63, including the inhalant [MEDICATION NAME]. The nurse administered the [MEDICATION NAME] discus and then closed the Diskus and put it back in the cart. The nurse failed to instruct the resident to rinse his mouth out with water and spit after the administration of this medication. The nurse, when questioned about rinsing out the resident's mouth, she stated she was not aware that they had to do this. A review of the instruction sheet provided with the medication found: ""After each dose, rinse your mouth with water and spit the water out. Do not swallow."" This medication was not administered according to the manufacturer's instructions. d) Resident #47 During the medication pass observation on 09/09/09 at 9:45 a.m., the nurse (Employee #83) administered medications to Resident #47, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. The nurse, when questioned about the [MEDICATION NAME] without Vitamin D, stated this was what the pharmacy sent and told them to administer when they called and told them they needed [MEDICATION NAME] with Vitamin D, and this was what they had been giving the residents. e) Resident #47 Employee #83 was observed preparing the medications for administration for Resident #47. She took out a vitamin from the bottle labeled ""Multi Vitamin with minerals"". When the nurse prepared to administer the medications, this nurse surveyor intervened and asked the nurse to check again to be sure this was the correct medication. The nurse checked the bottle's label against the resident's Medication Administration Record [REDACTED]."" She then obtained the other bottle of vitamins that did not contain minerals and administered a dose to the resident. .",2014-12-01
10764,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-09-10,520,F,0,1,667112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gathered on a revisit through observation, record review, and staff interview, the facility failed to implement a plan of action to correct identified quality deficiencies. The facility failed to correct deficient practices in six (6) of the same areas after the facility submitted an acceptable plan of correction indicating these concerns would be resolved prior to the end of August 2009. Repeat deficiencies were found in the areas of protection of residents funds, abuse investigating and reporting, care planning, medication errors, infection control, and isolation. This practice has the potential to affect all of the residents in this facility. Facility census: 77. Findings include: a) The facility's plan of correction for the standard survey completed on 06/25/09 was reviewed; however, deficient practices remained within respect to the following: 1. The facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. See citation at F161. 2. The facility failed to ensure an allegation of neglect was thoroughly investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. See citation at F225. 3. The facility failed to develop a plan of care to include the precautions to be taken during the care of residents who had a drug resistant infection. This was true for three (3) of three (3) residents reviewed who had a drug-resistant infection. See citation at F279. 4. The facility failed to administer a medication as ordered by the physician. This was a significant medication error affected one (1) of ten (10) sampled residents. See citation at F333. 5. The facility failed to implement an effective infection control program to prevent the potential spread of infections in the facility. The absence of an effective infection control program placed all residents in the facility at risk of acquiring an infection. See citation at F441. 6. The facility failed to implement transmission-based isolation precautions when indicated for residents with infections and failed to ensure residents were isolated according to the physician's orders [REDACTED]. See citation at F442. b) By virtue of the fact that repeat non-compliance was found on the on-site revisit completed on 09/10/09, the quality assurance committee failed to implement appropriate plans of action to correct identified quality deficiencies. .",2014-12-01
10765,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-11-18,514,B,0,1,667113,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 ""Investigation and Reporting"", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day follow-up reports for the facility. During interview with the social worker on the afternoon of 11/18/09, he stated he used the Nurse Aide Abuse Registry forms for submitting all reportable sent to the State survey agency (regardless of which program is responsible for reviewing and/or investigating the allegations); on the fax cover sheet, he would differentiate whether the report is to be sent to the Nursing Home Program or the Nurse Aide Abuse Registry, as they have the same fax numbers. These findings were again discussed at exit. As a result, the assistant director of nursing changed the policy at page 3 ""Investigation and Reporting"", to differentiate the reporting of allegations pertaining to only nursing assistants (to the nurse aide registry) from allegations that should be faxed to the State survey agency's long term care division. Also, the assistant director of nursing spoke her awareness now of the website where both programs' reporting forms can be located and downloaded for use. The director of nursing stated, at exit, that each nursing unit and the social worker now had the August 2009 revision for [MEDICATION NAME] on site for future reference. Correction of this component of the deficient practice was completed prior to exit. b) Review, on 11/17/09, of the infection control policies and procedures and of the Infection Control Tracking Form for logging resident infections for September, October and November 2009 revealed the Infection Control Tracking Form had a place for the room numbers, but no room numbers were written on the form. There was no place on the form to document the date for the re-cultures. Additionally, the form had a place for recording the results of the re-cultures, but the results were not always recorded. Interview with the infection control nurse, on 11/17/09 at 10:15 a.m., revealed she had a Daily Culture / Re-culture Monitoring form on the computer and was able to track and give answers for every question asked about the data on the current Infection Control Tracking Form (ICTF). Each Infection Control Tracking Form was differentiated by hall divisions (100, 200, 300, 400 halls), but she agreed that filling in the room numbers on the ICTF would be a good idea for tracking purposes, in the event residents changed rooms during the process. She spoke of plans to alter the form to include the re-culture dates and spoke agreement that completing the re-culture results (or recording why they did not require re-cultures) on the ICTF would be helpful to keep information in one easily observed location. The above findings were discussing during interview with the director of nursing 11/18/09 at 9:00 a.m., as well as the infection control nurse's plan to revise the form. The director of nursing spoke highly of the improvements in their infection control prevention, monitoring, and trending, and noted that numerous inservices in infection control issues have taken place in recent months. During exit these findings were discussed, and the infection control nurse presented a revised ICTF that now has a separate place to record room numbers and a separate place to record re-culture dates. Correction of this component of the deficient practice was completed prior to exit. c) Medication pass was observed with all medication nurses 11/17/09 on the 7:00 a.m. to 7:00 p.m. shift. Reconciliation of the medications, on 11/17/09 at approximately 4:30 p.m., revealed Resident #43 received [MEDICATION NAME] 0.1% one (1) drop to each eye during the medication pass at 8:40 a.m. on 11/17/09. Review of the original physician's orders [REDACTED]."" Review of the November 2009 monthly recapitulation of physician orders [REDACTED]."" Verification with a pharmacist revealed that Patinol only comes in a 0.1% strength solution; there is no [MEDICATION NAME] 2% solution. The medication nurse rechecked the bottle of Patinol that was used for Resident #43 this morning and agreed that it was Patinol 0.1%. During interview with the director of nursing on 11/18/09 at 9:00 a.m., she stated the pharmacy was supposed to notify nursing if there are any concerns or discrepancies in physician orders. At this point in time, she was not sure if the pharmacy notified nursing and nursing did not correct the order or if pharmacy failed to notify them. She stated an investigation will be forthcoming. She agreed that no harm occurred to Resident #43, as she got the correct medication in the correct dose at the correct time, but there was a transcription error. Review, on 11/18/09, of physician orders [REDACTED].",2014-12-01
10766,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,279,D,0,1,UDOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to develop a comprehensive plan of care to address all care and services needs of one (1) of thirty-seven (37) Stage II sample residents. Resident #72 had bilateral knee contractures and self-care deficits, but these issues were not addressed on her current care plan. Resident identifier: #72. Facility census: 94. Findings include: a) Resident #72 The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. Review of the resident's medical record, on 04/15/10 at 10:00 a.m., disclosed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her current care plan, dated 03/31/10, revealed neither her self-care deficits nor the presence of bilateral knee contractures was included in the plan. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The care plan nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the current care plan and acknowledged the resident's self-care deficit needs and bilateral knee contractures were not addressed. The MDS nurse stated she would revise the care plan to include knee contractures and her self-care deficits. On 04/21/10, the MDS nurse provided a copy of the resident's revised care plan dated 04/19/10. The revised care plan reported the resident required extensive assistance with activities of daily living and was dependent on staff for assistance. The revised care plan also noted the resident has decreased mobility due to contractures of bilateral lower extremities and contained interventions to be implemented to improve function and prevent further decline. .",2014-12-01
10767,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,318,G,0,1,UDOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, observation, resident interview, and record review, the facility failed to provide appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in range of motion for a resident with limited ROM for one (1) of thirty-seven (37) Stage II sample residents. There was no evidence a resident, who developed bilateral knee contractures since her admission to the facility, received the necessary care and treatment to increase her ROM and/or prevent a further decline. This deficient practice resulted in actual harm to Resident #72. Facility census: 94. Findings include: a) Resident #72 1. The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. 2. Record review, on 04/19/10 at 9:30 a.m., revealed a quarterly minimum data set assessment (MDS) with an assessment reference date of 03/19/10, on which the assessor noted the resident had limited range of motion (ROM) to one (1) leg with no loss of voluntary movement. This assessment information was contradicted by the physician's annual history and physical examination [REDACTED]. The assessment and care planning nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the 03/19/10 quarterly MDS and acknowledged it was inaccurate with respect to limitations in the resident's ROM. Employee #31 stated she ""just missed the contracture on the nurse's quarterly assessment, and the therapy screen reported no changes"". (See citation at F272.) 3. Resident #72's current care plan, dated 03/31/10, did not address the presence of bilateral knee contractures. Employee #31, when interviewed on 04/19/10 at 10:15 a.m., reviewed the current care plan and acknowledged the resident's bilateral knee contractures were not addressed, stating she would revise the care plan to include knee contractures. (See citation at F279.) 4. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The resident denied pain. 5. Medical record review, shortly after 10:00 a.m. on 04/19/10, revealed this [AGE] year old female resident did not have bilateral knee contractures at the time of her original admission to the facility on [DATE] or upon her return from a hospital stay on 03/04/08, and she did not have contractures at the time her physical therapy services were discontinued on 02/14/08. An order was written on 07/16/09 to discontinue both active-assist and passive ROM activities to her upper and lower bilateral extremities due to ""noncooperative behavior and c/o (complaints of ) pain""; however, there was no recognition of the presence of contractures of the lower extremities as noted by the physician on 03/03/09, nor was there evidence in the medical record the resident received treatment and services to prevent further decline in joint mobility after her discharge from restorative nursing services on 07/16/09. Review of her rehabilitation screening form found the following consecutive entries in the comments section: - On 12/16/08 - ""No changes in functional status. Pt (patient) would not benefit from skilled PT @ this time."" - On 12/24/08 - ""Pt not appropriate for skilled PT services @ this time. However, recommend Pt to get out of bed daily to promote socialization and mobility."" - On 03/21/09 - ""Pt not appropriate for skilled PT services 2 (secondary to) behaviors."" (This entry did not acknowledge the presence of severe bilateral contractures at the knees and hips as noted by the physician on 03/03/09.) (As of the morning of 04/19/10, there were no further entries reflective of any rehabilitation screening having occurred after 03/21/09.) 6. The rehabilitation services manager, a physical therapy assistant (PTA - Employee-#105), when interviewed on 04/19/10 at 3:30 p.m., revealed she had worked with the resident at the time she was admitted to the facility. The PTA confirmed the resident received physical therapy soon after her admission to the facility and was discharged from physical therapy to restorative nursing services on 02/14/08. The PTA further reported the resident was able to ambulate one hundred and fifty (150) feet with the assist of one (1) person at the time of her discharge to restorative nursing services. The PTA stated she was unaware of the resident's current bilateral knee contractures, and she reported there were treatments that could be helpful to prevent further decline and alleviate pain if present. The director of nurses (DON - Employee #89), when interviewed on 04/20/10 at 3:00 p.m., did not provide any additional evidence to reflect the resident received treatment and services to prevent bilateral knee contractures after 07/16/09, when she was discharged from the restorative nursing services. 7. Interview with the physical therapist (PT - Employee #106), on 04/20/10 at 3:15 p.m., revealed the resident was found to have ""bilateral knee contractures"". The PT acknowledged the resident currently was not receiving any therapy services. Subsequent review found an additional entry made on a rehabilitation screening, dated 04/19/10, stating, ""Resident exhibits profound bilateral full flexion contractures and confusion..."" Review found a physician's orders [REDACTED]. .",2014-12-01
10768,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,281,D,0,1,UDOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure that services provided to its residents met professional standards of quality for two (2) of thirty-seven (37) Stage II sample residents. One (1) resident received an incorrect dose of medication, and the facility failed to obtain a physician's order for hospice services for another resident. Resident identifiers: #47 and #21. Facility census: 94. Findings include: a) Resident #47 Observation, at 4:20 p.m. on 04/14/10, found a licensed practical nurse (LPN - Employee #44) administering medications to Resident #47. The LPN gave Resident #47 one (1) capsule [MEDICATION NAME] formula dosage- 60K/12K. The medical record, when reviewed on the morning of 04/15/10, revealed the current physician order was for three (3) capsules [MEDICATION NAME] formula 60K/12K three (3) times a day with meals. The LPN unit manager (Employee #94), when interviewed on 04/16/10 at 9:00 a.m., acknowledged Employee #44 gave the incorrect dose of medication. The correct order was for three (3) capsules of Creon. According to the ""Medical Office of Pharmacology: Review for medical assistant students and Professionals, Safety Guidelines - The Five Rights"", the five rights of medication administration are: 1. Right patient. 2. Right time and frequency of administration. 3. Right dose. 4. Right route of administration. 5. Right drug. (Internet resource web address: http://www.mapharm.com/safety.) The facility failed to ensure the right dose [MEDICATION NAME] administered to Resident #47. b) Resident #21 A review of Resident #21's medical record failed to find a physician's order for the Hospice services he had been receiving since 12/17/09. The director of nurses, when informed of this at 10:00 a.m. on 04/21/10, stated she would review the chart for the order. No physician's order for Hospice services for Resident #21 was found at the time of exit from the facility on 04/22/10. .",2014-12-01
10769,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,253,E,0,1,UDOR11,"Based on observation, staff interview, resident interview, and family interview, the facility failed to provide effective housekeeping and/or maintenance services to assure a resident environment free from persistent, unpleasant odors. Repeated observations during the course of this survey event from 04/13/10 through 04/22/10, found the presence of strong urine odors on the Hilltop wing and the facility's Alzheimer's specialty unit. This had the potential to affect more than an isolated number of residents. Facility census: 94. Findings include: a) Hilltop wing During general tour beginning at 11:30 a.m. on 04/13/10, this surveyor detected the odor of stale urine on the Hilltop wing in the hallway from Room #133 through Room #146. The odor did not appear to emanate from any individual resident room(s) and seemed centered in the hallway. This odor was present on each day of the survey. During an interview at 9:15 a.m. on 04/15/10, the daughter of Resident #3 stated there were often odors that ""smell like urine"" in the hallway outside of her mother's room. In an interview with Resident #301 in her room, she also mentioned the odor of urine in the hall outside of her room. In an interview with Resident #76 at 11:05 a.m. on 04/20/10, she stated she liked her room and where it was located, but she wished they could get rid of the odor of urine in the hall. A strong odor of urine was also present daily in the hall outside of the ""break room / medical records"". During an interview with the interim administrator, the nurse consultant, and the newly hired administrator at 3:30 p.m. on 04/21/10, they were made aware of these findings. No one denied the odors were present. The interim administrator stated the facility was trying very hard to eliminate these odors and speculated that a part of the problem may be in the brand of incontinence pads in use. b) Alzheimer's specialty unit During initial tour of the Alzheimer's unit on 04/13/10, a pervasive pungent odor of urine was noted throughout the entire unit. The carpeting throughout the unit was noted to be stained and dirty. Two (2) areas were noted to have stronger odors of urine - the television room and the quiet room, both of which contained chairs that smelled of urine. Odors of urine were detected on 04/14/10, 04/15/10, 04/20/10, 04/21/10, and 04/22/10. .",2014-12-01
10770,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,329,D,0,1,UDOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to ensure the resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #81 was seeing a consultant psychiatrist on an outpatient basis every two (2) months; per family request, this consultant physician was the only person permitted to make changes to her psychoactive medications. There was no documentation in the resident's medical record by the consultant physician of the clinical rationale for continued use of antianxiety and antipsychotic medications. Resident identifiers: #81. Facility census: 94. Findings include: a) Resident #81 Medical record review, on 04/20/10, revealed Resident #81 received [MEDICATION NAME] 0.5 mg by mouth every six (6) hours as needed for anxiety, [MEDICATION NAME] 2.5 mg two (2) times a day an 8:00 a.m. and 2:00 p.m. due to behavioral disturbances, and [MEDICATION NAME] 5 mg by mouth every night for behavioral disturbances. According to the medical record, her behaviors were stable for the past year. Additional information in the medical record revealed only the consultant physician was permitted to make any changes in the resident's medications. No information could be found in the medical record concerning any consultations this resident had with this physician. In an interview on 04/10/10 at 2:36 p.m., a licensed practical nurse (LPN - Employee #79) identified that, a year ago, Resident #81 had some serious problem behaviors. The family now comes in every two (2) months and takes her to their own physician; if changes are needed in her medications, he makes them. Otherwise, this consultant physician does not make any documentation in the medical record, nor does he review the resident's overall medical record. Employee #79 also reported that, for about the past year, Resident #81's behaviors have been stable. In an interview on the evening of 04/21/10, the coordinator of the Alzheimer's unit on which Resident #81 resides (Employee #20) was asked if the consultant physician makes any documentation in Resident #81's medical record. The following morning on 04/22/10, Employee #20 produced a note from a surveillance visit dated 03/09/10, which she had obtained the evening before. . .",2014-12-01
10771,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,225,E,0,1,UDOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based upon personnel record review and staff interview, the facility failed to verify whether prospective employees have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found for nine (9) of ten (10) employees' personnel records reviewed. Employee identifiers: #24, #80, #93, #104, #40, #74, #39, #47, and #20. Facility census: 94. Findings include: a) Employees #24, #80, #93, #104, #40, #74, #39, #47, and #20 When reviewed on 04/19/10 at 11:00 a.m., four (4) of five (5) sampled personnel records (Employees #24, #80, #93, #104) reviewed lacked verification that the State nurse aide registry had been checked prior to employment. When reviewed on 04/20/10 at 10:00 a.m., five (5) of five (5) sampled personnel records (Employees #40, #74, #39, #47, #20) reviewed lacked verification that the state nurse aide registry had been checked prior to employment. During an interview on 04/20/10 at 10:13 a.m., the payroll person (Employee #72) stated the facility was checking the State nurse aide registry on prospective nursing assistants only, but they will now initiate the registry check on all potential employees. .",2014-12-01
10772,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-04-22,272,D,0,1,UDOR11,". Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the accuracy of a quarterly assessment for one (1) of thirty-seven (37) Stage II sample residents. A resident's quarterly abbreviated minimum data set (MDS) assessment was inaccurate regarding physical functioning and structural problems related to contractures of the lower extremities. Resident identifier: #72. Facility census: 94. Findings include: a) Resident #72 The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. Record review, on 04/19/10 at 9:30 a.m., revealed a quarterly MDS with an assessment reference date (ARD) of 03/19/10, on which the assessor noted the resident had limited range of motion (ROM) to one (1) leg with no loss of voluntary movement. This assessment information was contradicted by the physician's annual history and physical examination [REDACTED]. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The nurse aide (Employee #103), when interviewed on 04/19/10 at 10:15 a.m., confirmed the resident had bilateral knee contractures with no orders for ROM activities by nursing staff or the application of a splint. The MDS nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the 03/19/10 MDS and acknowledged the MDS was inaccurate for limitations in ROM. The MDS nurse stated she ""just missed the contracture on the nurse's quarterly assessment, and the therapy screen reported no changes"". On 04/21/10 at 1:00 p.m., the MDS nurse provided a copy of the corrected MDS with a correction date of 04/19/10. The corrected MDS assessment identified the resident currently had limited ROM with full loss of voluntary movement to both lower extremities. .",2014-12-01
10773,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2010-06-30,323,D,0,1,UDOR12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to ensure the resident environment remained as free of accident hazards of was possible for one (1) of twelve (12) sampled residents. One (1) resident was observed on two (2) separate days to have medication left at the bedside without direct supervision of a nurse. Resident identifier: #21. Facility census: 97. Findings include: a) Resident #21 Observation, during initial tour of the facility shortly after 11:00 a.m. on 06/28/10, found Resident #21 asleep in her bed with the privacy curtain closed half way and an Advair inhaler lying on her chest. There were no nurses in the room at this time. A nurse (Employee #59) was immediately summoned from the hall by the surveyor. Upon entrance to the room, Employee #59 woke the resident and asked if she had used the inhaler; the resident replied in the affirmative, and the inhaler was removed from the room. Observation, on 06/30/10 at approximately 9:00 a.m., found Resident #21 awake in her room finishing breakfast with the privacy curtain closed half way and with an Advair inhaler lying on her overbed tray. When questioned, the resident said the nurse left the inhaler yesterday sometime after the evening meal. A nurse (Employee #17) was immediately summoned from the hall by the surveyor, and she removed the inhaler. Employee #17 stated she had not yet given Resident #21's morning medications and inhaler. She checked the medication administration record (MAR) and confirmed this resident receives Advair inhaler once in the morning and once in the evening. Review of active physician orders revealed an order for [REDACTED]. There were no physician's orders allowing this resident to self-administer medication. Review of the resident's most recent minimum data set (MDS) assessment, dated 06/14/10, found the answer to be ""No"" under Section S, ""Capable of self-administration of medications"". On 06/30/10 at 10:30 a.m., the director of nursing produced the facility's policy on medication administration and agreed that Item #14 of the policy, which states: ""Do not leave medications at bedside except as allowed per facility protocol"", was not followed in the above instances.",2014-12-01
10774,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2011-08-03,312,D,1,0,LP7S11,". Based on observation, staff interview, record review, and family interview, the facility failed to provide necessary services to maintain good grooming and personal hygiene for dependent residents as evidenced by a one (1) of eleven (11) sampled residents with long, untrimmed toenails and one (1) of eleven (11) sampled residents with stains on his shirt not changed in a timely manner following a meal. Resident identifiers: #64 and #24. Facility census: 95. Findings include: a) Resident #64 Observation of Resident #64's toenails, with assistance of nursing assistant (Employee #123) on 08/03/11 at 8:50 a.m., revealed all toenails on both feet were long and in need of trimming. The right great toenail was thickened and misshapened, with a graying discoloration of the nail bed. The left great toenail was long and curved inward toward the second toe, making an indentation on the skin at the corner of the second toe nailbed. The skin on the second toe was not open at this time. Interview with a nurse (Employee #111), on 08/03/11 at 8:55 a.m., found the facility contracted with a podiatrist who comes to the facility usually once per month in the middle of the month to trim residents' toenails. Employee #111 stated the nurses do weekly body audits and summaries on residents, and the interdisciplinary team does skin assessments monthly. The floor nurses and treatment nurse follow-up any identified issues, and the treatment nurse has the podiatry list. Employee #111 stated the most recent skin assessment for Resident #64 was completed on 07/27/11. Record review revealed the absence of any podiatry consultation reports on Resident #64's medical record. On 08/03/11 at 9:00 a.m., Employee #111 stated Resident #64 was admitted to and had resided on the Solano unit (Alzheimer's unit) since 05/05/11 until a hospitalization occurred in early July; following discharge from the hospital, she was readmitted to the Hilltop unit on 07/14/11. Employee #111 stated that, upon her re-admission on 07/14/11, a body audit was completed, but there was no mention made of the toenails. Interview with the health information management person (Employee #33), on 08/03/11 at 9:25 a.m., found that all the podiatrist's recent consultations hah been filed and confirmed there was none on record for Resident #64. Interview with another nurse (Employee #44), on 08/03/11 at 9:25 a.m., revealed that all newly admitted residents were put on the list to be seen by the podiatrist, and Resident #64's name was on the list in May 2011 for a podiatry consult. Since her name did not reappear in June 2011, this would indicate that she had been seen by the podiatrist in May and that she would be on the quarterly list thereafter. Based on this system, Resident #64 was due to be seen by the podiatrist for the second time in August 2011. A subsequent interview with Employee #44, on 08/03/11 at 10:00 a.m., found she called the podiatrist for verification of having completed a previous consult for Resident #64. She reported the podiatrist had not seen this resident. She further reported that, since he was going to be in their area tomorrow, he would see her for the initial visit on that date. Employee #44 observed Resident #64's left great hammer toe and agreed the left great toenail was cutting into the skin of the second toe. She stated she would apply a gauze pad as a wedge to prevent any skin breakdown. -- b) Resident #24 During an interview with a family member of Resident #24 on 08/01/11 at 2:13 p.m., she pointed to several moderately sized red stains on the lower part of his shirt and stated those stains were on that shirt yesterday and he wore it again today. Observation, on 08/01/11 at 6:24 p.m., found Resident #24 in a wheelchair in a small activity room not far from his room. The same red stains were on the same striped, hooded shirt he was observed wearing at 2:13 p.m. earlier that same afternoon. A large piece of brown-colored ground food was on the left chest area of his shirt, and food stains were around his mouth and chin. Two (2) nursing assistants and two (2) nurses (Employees #103 and #74) were in the room, the latter two (2) working on a large pile of paperwork. When asked about his wearing part of his supper, Employee #103 looked up and saw him and said they would clean him up. A nursing assistant took him to his room to change his shirt after she wiped his face and removed the piece of food from his shirt. During an interview with the administrator on the late morning of 08/03/11, she stated she would expect not more than two (2) hours lapse in time after a meal for a resident to be left with food stains on his clothing before being found and changed. .",2014-12-01
10775,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2011-08-03,323,E,1,0,LP7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to ensure the environment was as free as possible of accident hazards for three (3) of eleven (11) sampled residents and one (1) randomly observed resident who were observed ambulating on laminate and/or tiled floor in footwear that was not non-skid. Resident identifiers: #64, #18, #36, and #54. Facility census: 95. Findings include: a) Resident #64 Record review revealed Resident #64 experienced a fall while ambulating in the hallway of the Solana (Alzheimer's) unit, which resulted in a fractured hip and transfer to the hospital on [DATE]. - Review of the facility's incident / accident report investigation revealed Employee #61 (a nurse), who was in charge of the unit at the time of the fall, reported Resident #64 was wearing socks, but she did not think they were non-skid socks. Also, she reported there was nothing on the floor that would have potentially caused the fall. Review of the fall investigation worksheet revealed this resident had an unsteady gait, was confused, was wearing socks at the time of the fall, and had experienced a fall in the preceding thirty (30) days. - Review of Resident #64's care plan revealed a focus area for risk for falls. An intervention on the care plan was: ""Resident to wear non slip footwear"" (which was initiated was 05/05/11). - Review of a history and physical examination [REDACTED]""may have slipped while wearing socks and fell from a standing position"". - Interview with the director of nursing (DON) and the licensed social worker (LSW), on 08/02/11 at 2:45 p.m., revealed the facility had no policy prohibiting residents from walking in socks that were not non-skid if that was what the family brought in for them to wear. The DON stated the use of non-skid socks was a nursing intervention if it looked like a potential problem. The DON and the LSW agreed Resident #64's earlier fall on 06/28/11 was a fall out of bed. - In an interview on 08/02/11 at 5:45 p.m., the administrator stated it was not acceptable to have residents wear regular socks on laminate flooring or tile flooring (as was in the Alzheimer's unit). She said the Alzheimer's unit used to have carpeting around the double doors and porch area before it was renovated, so there was no written policy in place related to wearing of non-skid footwear. She said they recently talked about the use of slipper socks, but no policy had yet been written. -- b) Resident #18 Observation, on 08/01/11 at 5:50 p.m., found Resident #18 in the Solano dining room walking on both the tiled floor and the laminate flooring while wearing white socks with a pink line across the toes. At 6:06 p.m., the resident was observed walking in the hallway while talking with a nurse (Employee #95). The resident was still wearing the same socks. Inspection of the socks at that time found they were not non-skid socks. - During an interview with Employee #95 at 6:10 p.m., she stated she did not think Resident #18's socks had non-skid soles. She said this resident kept taking out the laces of her shoes, and they had spoken with the family about getting some other shoes with Velcro, noting that wearing shoes without laces was not safe. Employee #95 said they had gotten slippers from the laundry but she kept taking them off. - During an interview on 08/02/11 at 3:00 p.m., the DON was informed of the observations on the evening 08/01/11 of Resident #18 walking on the tiled and the laminate flooring in the Solana unit while wearing socks without non-skid soles, and after speaking with Employee #95, on 08/01/11 in the early evening, of the surveyor having seen this resident wearing non-skid socks at every observation on 08/02/11. - Review of the medical record revealed [DIAGNOSES REDACTED]. Review of Resident #18's care plan also revealed a problem of increased fall risk due to medications. -- c) Resident #36 Review of the care plan for Resident #36 found she was at high risk for falls and associated injury, had an unsteady gait at times, did not ask for assistance from staff, and had cognitive deficit and poor safety awareness. - Observation, on 08/01/11 at 5:50 p.m., found Resident #36 wearing white socks without non-skid soles while sitting in the dining room of the Solana unit. A repeat observation, at 6:12 p.m., found a nursing assistant (Employee #124) walking along side Resident #36 from the dining room to the ""porch"", where she sat in a chair with several other residents. During an interview with Employee #95 on 08/01/11 at 6:16 p.m., she agreed the socks Resident #36 was wearing did not have non-skid soles. She said this resident wore slippers this morning but took them off, and this nurse did not know where they are at present. She said Resident #36 can and does get up by herself and walk. - During an interview on 08/02/11 at 3:00 p.m., the DON was informed of observations on the evening 08/01/11 of Resident #36 walking on the tiled and the laminate flooring in the Solana unit while wearing socks without non-skid soles, and after speaking with Employee #95, on 08/01/11 in the early evening, of the surveyor having seen this resident wearing non-skid socks at every observation on 08/02/11. -- d) Resident #54 Observation, on 08/03/11 at 11:25 a.m., found Resident #54 walking in the dining area on the laminated flooring without shoes or non-skid footwear, wearing only regular socks. Interview with Employee #72, at this time, revealed one (1) of the residents on this unit would remove shoes from the feet of other residents and that keeping shoes on residents on this unit was difficult at times. During this interview, a nursing assistant was observed to obtain a pair of bedroom slippers and place them on Resident #54's feet. - Record review revealed Resident #54 was admitted four (4) months ago with [DIAGNOSES REDACTED]. Review of Resident #54's care plan revealed a problem / issue of increased fall risk, and approaches included wearing appropriate shoes when ambulating. This finding was reported to the administrator and DON at approximately noon on 08/03/11, with no further information provided. .",2014-12-01
10776,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2011-08-31,323,G,1,0,5Y7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for two (2) of forty-four (44) residents reviewed, to provide adequate supervision and/or assistive devices to prevent accidents, resulting in actual harm to one (1) of these residents. The interdisciplinary team developed a care plan to address risk of falls for Resident #84, who was admitted on [DATE] with poor coordination, impaired balance, unsteady gait, moderately impaired cognitive functioning, and multiple psychiatric diagnoses. Interventions to prevent falls included both environmental modifications (e.g., keep room clutter-free, keep commonly used items nearby, etc.), as well as interventions that relied on the resident to remember to ask for assistance and to exercise good judgment to promote her own safety. After she experienced her first fall in the facility on 07/11/11, a physical therapy screen recognized that the resident's poor safety awareness and impulsive behavior, as well as her instability, put her at risk for falling; however, the care plan was not revised to address these issues. Resident #84 sustained a second fall on 07/28/11, resulting in a contusion to the forehead requiring transfer to the emergency room . The interdisciplinary team also developed a care plan to address risk of falls for Resident #34, who had a [DIAGNOSES REDACTED]. The care plan interventions to promote safety required the resident to recall information (such as reminding her to ask for staff assistance, relying on her to remember to use a call bell, and educating her on safety risks), which were not appropriate for this resident. Review of incident / accident reports revealed she sustained fourteen (14) falls since her admission to the facility on [DATE]. Resident identifiers: #84 and #34. Facility census: 100. Findings include: a) Resident #84 When reviewed on 08/24/11, the medical record for Resident #84 divulged this resident was admitted to the facility on [DATE]. According to her admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/31/11, the assessor determined her brief interview for mental status (BIMS) score was ""12"", indicating this resident's cognitive status was moderately impaired. Additionally, the assessor noted the following [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined by facility staff, on Page 6 of 13 of the care plan, to be at: ""Risk for falls related to: Use of psychotropic medications, impaired balance, poor coordination, unsteady gait, potential for pain, involuntary movements r/t (related to) psychotropic medications."" This problem had been recognized on 06/06/11, according to the care plan document. Interventions to promote safety included: ""Have commonly used articles within easy reach. Resident to wear non slip footwear. Remind resident to use call light prior to ambulating or transfer. Reinforce need to call for assistance. Place call light within easy reach of resident. Evaluate effectiveness and monitor for side effects of psychotropic drugs. Ensure environment is free of clutter. Encourage resident to transfer and change positions slowly. Encourage resident to communicate needs / ask for assistance. Educate resident on Safety Risks."" - The facility incident / accident reports, when reviewed, disclosed this resident had experienced her first fall on 07/11/11, with the report stating: ""resident observed lying on the floor in front of the commode. ..."" The resident's care plan made no mention of this fall, with no new interventions developed. Further review of facility incident / accident reports revealed the resident sustained [REDACTED]. (resident) lying in front of her w/c (wheelchair). ..."" With this fall, the resident required transfer to the emergency room with a raised nodule and contusion to the forehead. - The unit manager for the Hilltop Unit (Employee #104), when interviewed on the afternoon of 08/24/11, stated that, although she found no direct update to the care plan, a physical therapy (PT) evaluation was completed following this fall. This PT evaluation was reviewed. Dated 07/12/11, the screening form stated a referral was received from nursing following a recent fall. The comments section of this form stated: ""Res. (resident) recently d/c (discharged ) from PT /c (with) known risk for falls (symbol for 'secondary to') instability & poor safety awareness / impulsive behavior. No (symbol for 'change') to warrant PT re-eval (re-evaluate)."" - Documentation on the PT screening form identified this resident's poor safety awareness and impulsive behavior contributed to falls; however, no changes were made to the resident's care plan to address this, with many interventions still relying on the resident to recall instructions or exercise good judgment (such as remembering to use the call light, asking for staff assistance prior to transferring / ambulating, recalling education given at an earlier date on safety risks, etc.). -- b) Resident #34 The medical record of Resident #34, when reviewed on 08/29/11, revealed the resident had been admitted to the facility on [DATE]. At the time of admission, the resident's active medical [DIAGNOSES REDACTED]. On the resident's initial care plan dated 03/30/11, the resident was recognized by facility staff to be at ""risk for falls related to: use of psychotropic medications, unsteady gait, history of multiple falls, generalized weakness, decreased safety awareness, non-compliance with requesting assistance with c/b (call bell) usage."" Interventions determined to be necessary to decrease the number of falls, or to prevent injury, included: ""Alarming floor mat. Alarming sensor pad to bed or c/c (cardiac chair). Up in chair for rest periods. Have commonly used articles within reach. Resident to wear non-slip foot wear. Ensure environment is free of clutter. Encourage resident to transfer and change position slowly. Encourage resident to communicate needs / ask for assistance. Educate resident on Safety Risks. Evaluate effectiveness and monitor for side effects of psychotropic drugs: Depakote, Klonopin."" All of the interventions were dated as initiated on 03/30/11, with the exception of a concave mattress to her bed which was initiated on 06/10/11, after the resident had already fallen eleven (11) times. - Review of the facility incident / accident reports revealed that, since the time of her admission, the resident had fallen fourteen (14) times. With many of the falls, an entry was handwritten on the care plan which stated the problem as being the resident had experienced a fall and the date of the fall. The goals that were added were: ""Will remain free of injury"", ""Will have no serious injury', and ""Will have no complications"". Approaches were to assist as needed, keep call bell in reach, monitor the frequency of falls and/or re-direct as needed. There was no evidence that the resident had been evaluated for cause of the falls, patterns of times of falls, etc. in an attempt to prevent the falls. No different or additional interventions had been attempted when the resident continued to fall. - Review of her admission MDS with an ARD of 03/21/11 revealed a BIMS score of ""03"", with no ability to recall three (3) words spoken to her earlier during the interview. A significant change in status MDS with an ARD of 06/06/11 revealed a BIMS score of ""04"", with the ability to recall only two (2) of three (3) words spoken to her earlier in the interview only after cuing. According to the resident assessment instrument user's manual for the MDS 3.0, a BIMS score of ""0"" to ""7"" indicates the resident's cognitive status is severely impaired. Therefore, interventions that required the resident to recall information (such as reminding her to ask for staff assistance, relying on her to remember to use a call bell, and educating her on safety risks) were not appropriate for this resident. .",2014-12-01
10777,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2011-08-04,204,D,1,0,S9PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to provide sufficient preparation and notice to a resident and her family to ensure an orderly discharge from the facility in a manner that minimizes unnecessary and avoidable anxiety. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): ""3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which is not working. 3:20pm, contacted (name of director of nursing) RN, DON, also contacted (name of social worker) SS, who will be contacting (name of administrator) CEO. 3:25pm, Contacted (name of resident's responsible party) MPOA (medical power of attorney)who is in agreement to transport resident to FGH Behavior unit. 3:50pm, left message for Dr. (name). 3:50pm Contacted MCRS to transport resident to FGH for evaluation. Son, (name) MPOA in to see resident. (Name) Called and was told of behavior and going to FGH ... 4:15pm, MCRS here to transport resident to FGH for evaluation. Also contacted FGH ER and spoke with Nurse (name) who was informed of residents behavior and arrival by squad. 5:18pm, Dr. (name) returned call re: residents behavior and transport to FGH for evaluation."" - Review of documentation concerning Resident #43's discharge, conducted on 08/04/11 at 1:00 p.m., disclosed a notice of resident transfer and bedhold policy dated 06/26/11. The form was filled out by hand and stated ""(Name of Resident #43) will be transferred to FGH (local hospital) due to: behavior."" There followed a statement of facility bedhold policy, which included the statement: ""It is the policy of John Manchin Sr. Healthcare to hold the resident's bed for 30 days ... The bedhold will continue unless permanent determination is made regarding the resident's need for care the facility is unable to provide."" There followed a section Titled ""State Bed Hold Policy"", a statement that ""The resident has the right to appeal this action to the agencies listed below"", and a listing of contact information for the West Virginia Inspector General, the West Virginia Commission on Aging, West Virginia Advocates, and the Regional Ombudsman. The form concluded with the following: ""I certify that this notification was given to the party named above: (name of Resident #43), and was dated by hand 6/26/11. Signature of staff member was completed by hand as (Employee #68, LPN)."" The final section of the transfer notice stated: ""Verification of receipt of notification: This acknowledges that I received the notice of resident transfer and bedhold policy."" The ""signature of resident / legal representative"" field was blank. - In an interview with Employee #68 on 08/03/11 at 2:45 p.m., when asked if she had given a copy of the form to the resident or to the MPOA, replied that that form was not given to either of those individuals, that it was a form that was sent with the emergency squad when a resident is sent out. - During an earlier interview with the nurse manager of the Behavioral Health Unit on 08/03/11 at 11:00 a.m., she had pointed out that the facility sends a form when residents are transferred for evaluation that states they will hold the resident's bed for thirty (30) days. d) A visit was made to the Behavioral Health Unit at Fairmont General hospital on [DATE] at 11:00 a.m. The director and the nurse manager of this unit were interviewed regarding the issues surrounding Resident #43's admission for evaluation and her subsequent discharge to a nursing facility in Grafton. Supporting documentation was requested and provided. The nurse manager stated they had expected Resident #43 to return to the facility, as she had following a brief admission for evaluation in March 2011. Documentation was reviewed as follows: A psychosocial assessment, completed 07/05/11, included under the section ""CURRENT LIVING SITUATION / SOCIAL AND COMMUNITY SUPPORT"": ""... She should be able to return to John Manchin Senior Center pending a completed PAS (pre-admission screen). That will be continuously evaluated by the treatment team; however in a conversation on June 28, 2011, with (Name of son), he stated that it was his goal for their mother to return to that facility."" Under the section ""SUMMARY AND RECOMMENDATIONS"" was found: ""... She should be able to return to John Manchin Senior center following discharge."" Under the section ""INITIAL TREATMENT GOALS / INTERVENTIONS"" was found: ""... Goals: 1. Prevention of deterioration. 2. Decrease any agitation, aggressiveness and wandering behaviors. 3. Help reorient the patient and maybe decrease some of the agitation through ongoing reorientation to time, place, and situation. Interventions: 1. Medication stabilization. 2. One-on-one interaction to develop some effective coping skills and help facilitate group and individual sessions."" Under the section ""INITIAL DISCHARGE PLANNING"" was found: ""... Return to John Manchin Senior Healthcare Center where she currently resides."" Phone contact notes stated: On 06/29/11 - ""Spoke with (name) at John Manchin Nursing home this day. Discussed DC (discharge) for Friday. (Name) states that PT's (patients) will need to be transported to that facility before 12 so that prescriptions can be filled."" On 06/30/11 - ""Spoke with (nursing home's social worker) this day regarding DC (discharge) for (Resident #43). Discussed (Resident #43's) recent aggressiveness and behaviors. Discussed a possible DC for Tuesday 7/5/11 pending continued observation. The initial projected DC date was to be 7/1/11, however it is the opinion of TX (treatment) teams at both facilities that PT needs more observation and time for med adjustments to occur."" On 07/07/11: ""Attempted to contact (name of social worker) at Manchin Healthcare to discuss DC for 7/8/11 as per discussion with Dr. (name) this day. (Name of social worker) was unavailable, message was left on her personal answering machine."" On 07/11/11: ""Spoke with (nursing home's social worker) at John Manchin Healthcare this day to discuss PT discharge. (social worker) states that John Manchin will not be able to accept PT back, states that this decision is based PT safety concerns and OHFLAC regulations. (social worker) states that she did not agree to accept patient back in her conversation with Dr. (name) which occurred on Friday 7/8/11."" A treatment progress note dated 07/11/11 stated: ""Met with PT's son's (names), and PT's daughters (names) this day following a discussion with (nursing home's social worker) at John Manchin Sr. Healthcare. On this day PT was to be DC as per a conversation that occurred on 7/8/11 between (social worker) and Dr. (name). When the RN on duty called John Manchin to give DC report (hospital) was informed that John Manchin would not accept the PT back. Discussed with PT's family several options for placement, including (name of another nursing home) which had been contacted with referral information. PT's family prompted this author to make several other referrals, which were faxed this day. PT's family is visiting several nursing homes this day, will contact tomorrow."" It was apparent that both Resident #43's family and staff at the Behavioral Health Unit were expecting the resident's return to John Manchin right up until the refusal expressed over the telephone on 07/11/11. The resident was subsequently discharged to another area facility. - An interview was conducted with a son of Resident #43 by telephone at 11:30 a.m. on 08/03/11. He stated the family did not have enough time to transfer their mother to another facility. He further stated he felt administration at this facility did not seem to understand how to care for Alzheimer's patients. He also stated the floor nurses at the facility did the best they could, but administration just did something drastic. - In an interview with the facility's health information management director (Employee #45) on 08/03/11 at 1:25 p.m., when asked to clarify the facility's bedhold policy, she stated the facility holds the bed of a transferred resident for thirty (30) days regardless of payor source or availability of bedhold days through the Medicaid program. She stated that, if a resident's Medicaid allotment of twelve (12) paid bedhold days had already been used, the facility would still hold the bed free of charge for thirty (30) days. - The only documented meeting between the facility's interdisciplinary team and Resident #43's MPOA was a care plan review meeting held on 04/06/11. A social services note stated: ""Annual Assessment was done today for (Name of Resident #43). Her son and MPOA, (name), attended the meeting. The IDT (interdisciplinary team) members reviewed the care needs of (Resident #43) with (name of son) and a new plan of care will be done reflecting new changes in her care."" A review of the care plan that was developed found the problems / strengths identified were in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to Resident #43's MPOA about the continued stay of Resident #43 at this facility. There were no other documented discussions or meetings with the family. - A review of social services notes found there was no note regarding the resident's transfer to the Behavioral Health Unit at the local hospital on [DATE]. There was a note dated 06/27/11 which stated: ""Called and cancelled (Resident #43's) appointments with physical therapy this week."" This was the final social services note in the medical record. A review of physician's progress notes found the last documented note was dated 06/15/11, and stated: ""(Rt) (right) ear redness (illegible) tissue. Pressure related sleep changes."" The nurses' note from that visit stated: ""MD vs (visit) and examined right ear that was red and stated that it was pressure related from lying on the right side. Orders received to DC (discontinue) [MEDICATION NAME] at this time."" There was no further documentation found by the attending physician. physician's orders [REDACTED].#43. It was explained by Employee #41 (a registered nurse assessment coordinator) that, since the electronic medical record was closed, all orders printed had ""dc"" at the beginning and "" "" at the end. The final physician's orders [REDACTED]."" There were no further orders for permanent discharge from the facility. A discharge summary form, dated 07/13/11 and signed Employee #41, stated the resident was discharged to the local hospital. The course of treatment while in the nursing home was described as: ""Alert, but confusion. Needs assist. Of one for all care to ensure optimum level of personal hygiene. Independent ambulation. Needed supervision to prevent resident from leaving facility property. Redirection for aggressive behavior."" Pertinent diagnostic findings were described as ""N/A"" (not applicable). Essential information regarding illnesses or problems was described as: ""Increased confusion, Redirection not always effective. Repeated attempts to leave facility + (and) facility property."" Restorative procedures were described as: ""Psyche consults medication adjustments."" The section titled ""Written discharge instructions given to"" was not completed. The section for Physician Signature was blank. - The administrator, (Employee #2), DON (Employee #46), and social worker (Employee #34) all stated, during an interview of 08/02/11 at 3:00 p.m., that they had ongoing discussions with the family about their concerns for the safety of Resident #43 and their growing conviction that they could no longer ensure her safety as a resident of their facility. There was, however, no documentation to support that those exchanges occurred, and there was documentation that showed that both the Behavioral Health Unit at hospital and the family were clearly expecting the resident to be readmitted until the phone conversation of 07/11/11. The family was then required to make an unplanned admission to another nursing facility that provided the same level of care. - The record of Resident #43, whom the facility maintained was transferred / discharged due to safety reasons, did not reflect the process by which the facility concluded that transfer or discharge was necessary and did not contain evidence of accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines, and there was no documentation from the resident's physician that the resident was transferred / discharged for the sake of the resident's welfare and/or the resident's needs could not be met in the facility. .",2014-12-01
10778,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2011-08-04,202,D,1,0,S9PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to adequately document the reasons and conditions surrounding a resident's discharge from the facility due to safety reasons. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): ""3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which is not working. 3:20pm, contacted (name of director of nursing) RN, DON, also contacted (name of social worker) SS, who will be contacting (name of administrator) CEO. 3:25pm, Contacted (name of resident's responsible party) MPOA (medical power of attorney)who is in agreement to transport resident to FGH Behavior unit. 3:50pm, left message for Dr. (name). 3:50pm Contacted MCRS to transport resident to FGH for evaluation. Son, (name) MPOA in to see resident. (Name) Called and was told of behavior and going to FGH ... 4:15pm, MCRS here to transport resident to FGH for evaluation. Also contacted FGH ER and spoke with Nurse (name) who was informed of residents behavior and arrival by squad. 5:18pm, Dr. (name) returned call re: residents behavior and transport to FGH for evaluation."" - Review of documentation concerning Resident #43's discharge, conducted on 08/04/11 at 1:00 p.m., disclosed a notice of resident transfer and bedhold policy dated 06/26/11. The form was filled out by hand and stated ""(Name of Resident #43) will be transferred to FGH (local hospital) due to: behavior."" There followed a statement of facility bedhold policy, which included the statement: ""It is the policy of John Manchin Sr. Healthcare to hold the resident's bed for 30 days ... The bedhold will continue unless permanent determination is made regarding the resident's need for care the facility is unable to provide."" There followed a section Titled ""State Bed Hold Policy"", a statement that ""The resident has the right to appeal this action to the agencies listed below"", and a listing of contact information for the West Virginia Inspector General, the West Virginia Commission on Aging, West Virginia Advocates, and the Regional Ombudsman. The form concluded with the following: ""I certify that this notification was given to the party named above: (name of Resident #43), and was dated by hand 6/26/11. Signature of staff member was completed by hand as (Employee #68, LPN)."" The final section of the transfer notice stated: ""Verification of receipt of notification: This acknowledges that I received the notice of resident transfer and bedhold policy."" The ""signature of resident / legal representative"" field was blank. - In an interview with Employee #68 on 08/03/11 at 2:45 p.m., when asked if she had given a copy of the form to the resident or to the MPOA, replied that that form was not given to either of those individuals, that it was a form that was sent with the emergency squad when a resident is sent out. - During an earlier interview with the nurse manager of the Behavioral Health Unit on 08/03/11 at 11:00 a.m., she had pointed out that the facility sends a form when residents are transferred for evaluation that states they will hold the resident's bed for thirty (30) days. - An interview was conducted with a son of Resident #43 by telephone at 11:30 a.m. on 08/03/11. He stated the family did not have enough time to transfer their mother to another facility. He further stated he felt administration at this facility did not seem to understand how to care for Alzheimer's patients. He also stated the floor nurses at the facility did the best they could, but administration just did something drastic. - In an interview with the facility's health information management director (Employee #45) on 08/03/11 at 1:25 p.m., when asked to clarify the facility's bedhold policy, she stated the facility holds the bed of a transferred resident for thirty (30) days regardless of payor source or availability of bedhold days through the Medicaid program. She stated that, if a resident's Medicaid allotment of twelve (12) paid bedhold days had already been used, the facility would still hold the bed free of charge for thirty (30) days. - The only documented meeting between the facility's interdisciplinary team and Resident #43's MPOA was a care plan review meeting held on 04/06/11. A social services note stated: ""Annual Assessment was done today for (Name of Resident #43). Her son and MPOA, (name), attended the meeting. The IDT (interdisciplinary team) members reviewed the care needs of (Resident #43) with (name of son) and a new plan of care will be done reflecting new changes in her care."" A review of the care plan that was developed found the problems / strengths identified were in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to Resident #43's MPOA about the continued stay of Resident #43 at this facility. There were no other documented discussions or meetings with the family. - A review of social services notes found there was no note regarding the resident's transfer to the Behavioral Health Unit at the local hospital on [DATE]. There was a note dated 06/27/11 which stated: ""Called and cancelled (Resident #43's) appointments with physical therapy this week."" This was the final social services note in the medical record. A review of physician's progress notes found the last documented note was dated 06/15/11, and stated: ""(Rt) (right) ear redness (illegible) tissue. Pressure related sleep changes."" The nurses' note from that visit stated: ""MD vs (visit) and examined right ear that was red and stated that it was pressure related from lying on the right side. Orders received to DC (discontinue) [MEDICATION NAME] at this time."" There was no further documentation found by the attending physician. physician's orders [REDACTED].#43. It was explained by Employee #41 (a registered nurse assessment coordinator) that, since the electronic medical record was closed, all orders printed had ""dc"" at the beginning and "" "" at the end. The final physician's orders [REDACTED]."" There were no further orders for permanent discharge from the facility. A discharge summary form, dated 07/13/11 and signed Employee #41, stated the resident was discharged to the local hospital. The course of treatment while in the nursing home was described as: ""Alert, but confusion. Needs assist. Of one for all care to ensure optimum level of personal hygiene. Independent ambulation. Needed supervision to prevent resident from leaving facility property. Redirection for aggressive behavior."" Pertinent diagnostic findings were described as ""N/A"" (not applicable). Essential information regarding illnesses or problems was described as: ""Increased confusion, Redirection not always effective. Repeated attempts to leave facility + (and) facility property."" Restorative procedures were described as: ""Psyche consults medication adjustments."" The section titled ""Written discharge instructions given to"" was not completed. The section for Physician Signature was blank. - The administrator, (Employee #2), DON (Employee #46), and social worker (Employee #34) all stated, during an interview of 08/02/11 at 3:00 p.m., that they had ongoing discussions with the family about their concerns for the safety of Resident #43 and their growing conviction that they could no longer ensure her safety as a resident of their facility. There was, however, no documentation to support that those exchanges occurred, and there was documentation that showed that both the Behavioral Health Unit at hospital and the family were clearly expecting the resident to be readmitted until the phone conversation of 07/11/11. The family was then required to make an unplanned admission to another nursing facility that provided the same level of care. The record of Resident #43, whom the facility maintained was transferred / discharged due to safety reasons, did not reflect the process by which the facility concluded that transfer or discharge was necessary and did not contain evidence of accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines, and there was no documentation from the resident's physician that the resident was transferred / discharged for the sake of the resident's welfare and/or the resident's needs could not be met in the facility. .",2014-12-01
10779,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2011-08-04,280,D,1,0,S9PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and revise a resident's care plan as the resident's status changed, with input from all appropriate staff and family. This was found for one (1) of eight (8) residents sampled. Resident identifier: #43. Facility census: 41 Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and was subsequently discharged permanently from the nursing home on 07/11/11. - An annual minimum data set Assessment (MDS), with an assessment reference date (ARD) of 04/03/11 for Resident #43 was reviewed at 4:00 p.m. on 08/03/11. This assessment documented that, during the 7-day lookback period ending on 04/03/11, Resident #43 was able to make herself understood and clearly understood others. She was documented as having no physical behavioral symptoms but as having verbal behavioral symptoms directed toward others on one (1) to three (3) days during the 7-day lookback period. The facility documented that the resident's behaviors did not have any impact on her or on others. The facility documented that Resident #43 exhibited wandering behavior four (4) to six (6) days during the 7-day lookback period, but that these behaviors did not put her at significant risk of getting to a potentially dangerous place, nor did the wandering intrude on the privacy or activities of others. - Based upon the MDS of 04/03/11, an interdisciplinary care plan was developed, and a meeting was conducted with the interdisciplinary team and the resident's son and medical power of attorney (MPOA) on 04/06/11. This care plan, when reviewed at 4:15 p.m. on 08/03/11, included problems / strengths to be addressed in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to the resident's responsible party about her continued placement at this facility. - After the 04/03/11 care plan meeting, Resident #43 experienced multiple elopements and episodes of physical aggression as documented in nursing notes - the most significant being: - An elopement on 04/09/11, when the facility was called by a member of the community and informed that the resident was found on Market Street, - An elopement on 04/10/11, when the resident went outside without telling staff, - An elopement on 04/14/11, when the resident was found outside, - An elopement on 06/16/11, when the resident was found walking outside, - An elopement on 06/22/11, when the resident was out in the parking lot and struck the facility's social worker, and - An elopement on 06/26/11, after which the resident was found on Market Street near Wesbanco and a member of the community returned the resident to the facility. There were no revisions noted to the resident's care plan to address these elopements with physical aggression, which were not included in the original plan of care discussed in the meeting of 04/03/11.",2014-12-01
10780,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-06-08,157,D,1,0,MZQB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made ""do not resuscitate"" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use"" (created on [DATE]) G - ""minimize skin breakdown risks"" (created on [DATE]) I - ""... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..."" (created on [DATE]) - P - ""Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising"" (created on [DATE]) G - ""Will have no adverse effects"" (created on [DATE]) and ""Will maintain lab values within therapeutic range (created on [DATE]) I - ""Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and reports adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care."" (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P - ""At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]"" created on [DATE]) G - Minimize risk for falls"" (created on [DATE]) I - ""Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). "" - 4. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident ""missed his chair"" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed): ""resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning."" The LPN also noted the type of incident as a ""(f)all without injury (or minor injury)"". Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and ""resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. "" - 5. The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot."" An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue."" At 6:00 p.m. on [DATE], another nurse wrote: ""Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. "" At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 6. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 7. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written): ""Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%."" The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated: ""Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. "" The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated: ""(Name of transport service) here to p/u (pick up) for ortho appt. "" There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 8. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 9. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141 ""underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm."" The report read: ""The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding."" He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. - 10. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was ""old"" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was ""probably"" old and that a ""large amount of acute bleeding"" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). - 11. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, who would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was ""old"", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's ""right"" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 12. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: ""Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H2O given with meds. ..."" There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: ""Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain."" There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: ""Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility."" The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):""... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..."" Under the heading ""Assessment and Plan"" was: ""1.[MEDICAL CONDITION]ly of urinary origin. ..."" - The facility's policy titled ""Catheter Care: Indwelling Catheter"" (dated "",[DATE]""), provided by the facility on [DATE], contained the following under the heading ""Suggested Documentation"": ""- Care provided and reaction to procedure, size of catheter and balloon. ""- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians."" - Review of the resident's care plan, with a print date of [DATE], found the following problem statement: ""Use of indwelling urinary catheter D/T (due to) [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder places him at risk for bladder infections, trauma / urethral erosion."" This problem statement had a ""created"" date of [DATE]. Interventions associated with this problem included: ""... Monitor and report to physician any signs of UTI (urinary tract infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain / burning. ... Monitor for and report any changes in amount, color, or odor of urine. ..."" Both of these interventions had ""created"" dates of [DATE]. - On [DATE] at approximately 4:00 p.m., the DON, the DCD (Employee #24), and a corporate nurse consultant (Employee #195) were presented with the nursing notes from [DATE] and [DATE]. They had no information to offer as to why the resident's attending physician was not notified when these abnormal findings, indicative of an acute change in condition, were documented in the resident's medical record. .",2014-12-01
10781,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-08-25,157,D,1,0,1HRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made ""do not resuscitate"" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use"" (created on [DATE]) G - ""minimize skin breakdown risks"" (created on [DATE]) I - ""... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..."" (created on [DATE]) - P - ""Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising"" (created on [DATE]) G - ""Will have no adverse effects"" (created on [DATE]) and ""Will maintain lab values within therapeutic range (created on [DATE]) I - ""Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and reports adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care."" (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P - ""At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]"" created on [DATE]) G - Minimize risk for falls"" (created on [DATE]) I - ""Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). "" - 4. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident ""missed his chair"" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed): ""resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning."" The LPN also noted the type of incident as a ""(f)all without injury (or minor injury)"". Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and ""resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. "" - 5. The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot."" An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue."" At 6:00 p.m. on [DATE], another nurse wrote: ""Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. "" At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 6. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 7. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written): ""Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%."" The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated: ""Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. "" The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated: ""(Name of transport service) here to p/u (pick up) for ortho appt. "" There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 8. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 9. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141 ""underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm."" The report read: ""The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding."" He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. - 10. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was ""old"" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was ""probably"" old and that a ""large amount of acute bleeding"" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). - 11. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, who would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was ""old"", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's ""right"" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 12. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: ""Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. ..."" There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: ""Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain."" There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: ""Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility."" The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed): "" ... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..."" Under the heading ""Assessment and Plan"" was: ""1.[MEDICAL CONDITION]ly of urinary origin. ..."" - The facility's policy titled ""Catheter Care: Indwelling Catheter"" (dated "",[DATE]""), provided by the facility on [DATE], contained the following under the heading ""Suggested Documentation"": ""- Care provided and reaction to procedure, size of catheter and balloon. ""- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians."" - Review of the resident's care plan, with a print date of [DATE], found the following problem statement: ""Use of indwelling urinary catheter D/T (due to) [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder places him at risk for bladder infections, trauma / urethral erosion."" This problem statement had a ""created"" date of [DATE]. Interventions associated with this problem included: ""... Monitor and report to physician any signs of UTI (urinary tract infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain / burning. ... Monitor for and report any changes in amount, color, or odor of urine. ..."" Both of these interventions had ""created"" dates of [DATE]. - On [DATE] at approximately 4:00 p.m., the DON, the DCD (Employee #24), and a corporate nurse consultant (Employee #195) were presented with the nursing notes from [DATE] and [DATE]. They had no information to offer as to why the resident's attending physician was not notified when these abnormal findings, indicative of an acute change in condition, were documented in the resident's medical record. .",2014-12-01
10782,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2011-08-31,504,D,1,0,ZR0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain laboratory services in accordance with physician orders [REDACTED]. Resident identifier: #70. Facility census: 82. Findings include: a) Resident #70 Review of Resident #70's medical record, conducted on 08/30/11 and 08/31/11, revealed this [AGE] year old female had the following Diagnoses: [REDACTED]. Review of the resident's physician orders [REDACTED]."" Review of the medical record found no evidence the UA and C&S were completed as ordered. On 08/31/11 at approximately 12:30 p.m., interview with the director of nursing (DON - Employee #102) confirmed the facility did not complete the UA and C&S. The DON stated the facility had approximately five (5) nurses who worked to try and get a urine specimen from the resident, but they had difficulty because of her incontinence. She went on to say they attempted to use the method of straight catheterization to obtain the urine sample, but this did not work either as they ran into difficulty and could not complete the procedure. On 08/31/11 at approximately 4:00 p.m., the DON informed this surveyor that the resident's physician knew the facility did not obtain the UA and C&S, but he did not order anything additional due to the order he had written for [MEDICATION NAME] (antibiotic) 500 mg. Subsequent review of the medical record found no evidence to reflect staff made the physician aware of their inability to obtain a urine specimen for the UA and C&S.",2014-12-01
10783,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,154,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal."" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, ""I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed."" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, ""The HCS was notified multiple times and did not return the calls."" She further stated, ""When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights."" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, ""Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary."" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, ""I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS."" .",2014-12-01
10784,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,250,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility did not provide medically-related social services to one (1) of five (5) sampled residents. Resident #72 lacked the capacity to understand and make informed healthcare decisions. The facility discontinued all of his medications, labs and diagnostic tests, and his weights without having approval from the resident's health care surrogate (HCS). Nursing staff attempted to notify the HCS before discontinuing the medication and weights, and the HCS did not respond to the telephone notifications. The nursing staff notified the physician, who gave orders to discontinue the medications and weights. The social services director, who was unaware of the resident's refusals and unaware that the HCS had failed to respond to notification attempts by the facility, did not ensure the resident had representation from an HCS who was acting in accordance with the resident's known wishes or, if these were not known, his best interests. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal."" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, ""I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed."" -- A review of social service notes for June 2011 found no acknowledgement of awareness that the HCS was not responding to calls from the nursing staff. -- A review of the resident's initial care plan revealed the following: Focus: ""History of hoarding of medication in oral cavity and then saving them in drawer."" Goals: ""Provide safe environment daily through next review."" Interventions: ""Observe resident for hoarding meds in mouth. If hoarding in mount present, crush medications. If resident resists crushing meds, check oral cavity after administering."" - Focus: ""At risk for changes in mood r/t (related to) resident's desire to transfer facilities and lack of family contact at times."" Goals: ""Will maintain involvement with ADL (activities of daily living) performance and social activities."" Interventions: ""Assess for physical / environmental changes that may precipitate change in mood. Observe for and report any changes in mood. Offer choices to enhance sense of control. Provide emotional support/education to patient and/or family as needed. Validate feelings of loss."" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, ""The HCS was notified multiple times and did not return the calls."" She further stated, ""When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights."" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, ""Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary."" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, ""I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS."" .",2014-12-01
10785,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,360,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a nourishing diet that meets the daily nutritional and special dietary needs of one (1) of five (5) sampled residents. Record review revealed Resident #72 weighed 88 pounds (#) on admission and now weighed 98#. The resident's ideal body weight range was 145# to 165#, and the resident was not ordered an enhanced diet to promote weight gain. Resident identifier: #72. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident's weight fluctuated from 88.2 pounds (#) on admission to 102#. The resident's weight on 08/02/11 was 98#. An interview with the registered dietitian (RD - Employee #129), on 08/02/11 at 11:00 a.m., revealed the RD did not understand why the resident was not receiving enhanced foods related to his weight loss. She stated, ""He should have received the enhanced food with the diet orders on admission."" She stated, ""I will give the resident enhanced food on his diet."" An interview with the dietary manager (Employee #11), on the morning of 08/02/11, revealed the resident did not have an enhanced diet related to the amount of snacks in his room. The dietary manager reported the family brought in snacks, crackers, peanut butter, and candy and that was what he ate all of the time. She felt that, with the amount of snacks in the resident's room, he did not need an enhanced diet. A review of the resident's care plan on admission revealed the following: Focus: ""Potential for nutritional impairment r/t (related to) prior history of malnutrition and less than 50% of food consumed and history of GERD."" Goals: ""Will consume / tolerate 50% of meals and 75%-100% of fluids provided daily through next review."" Interventions: ""Encourage and assist as needed to consume mechanical soft diet. Administer [MEDICATION NAME] per MD orders. Resident pretends to be sleeping when tray is served or he is on phone and doesn't eat food while it is hot. When he pretends he is sleeping, he does not rouse when stimulated to open eyes and eat. Re-heat food as needed. Discontinue weights due to resident does not eat meals, but eats snacks family brings in. Resident consumes a lot of snack food that family brings, will overindulge to the point of vomiting at times. Encourage to sit upright with meals and afterward for 1 hour. Magic cup served with each meal on tray."" A review of the nutrition risk assessment on 04/09/10 (date of admission), the resident was assessed as weighing 88.2#. The resident was consuming all of the Ensure nutritional supplement. The resident's ideal body weight was listed as 145# to 165#. The resident was consuming 100% of his meals. A dietary note, dated 08/17/10, stated the resident's meal intake was 50% with all meals. The resident was receiving [MEDICATION NAME] (an appetite stimulant) and Ensure three (3) times a day with meals. His current weight 102.8#. On 05/01/11, the resident was receiving Ensure one (1) time a day related to refusing to drink the Ensure three (3) times a day. On 06/23/11, the physician discontinued all medications (except those ordered on a PRN (as needed) basis) and all weights related to the resident's refusal.",2014-12-01
10786,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,157,D,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the responsible party and/or physician, for one (1) of seven (7) sampled residents, when acute changes in condition occurred, and failed to notify the responsible party when changes were made in medication and treatment orders as a result of this acute changes in condition. Resident #14 developed a ""blister"" on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. There was no evidence the family was informed of the ""blister"" or the topical antibiotic that was ordered on [DATE] to treat this area. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). There was a lack of evidence to reflect the family had been notified of this new medication or the reason for its use. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be ""blackish / brownish"" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to ""awaiting delivery from pharmacy"". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a ""blister"" on the left great toe, to which the podiatrist applied [MEDICATION NAME] (a topical antibiotic); the podiatrist also recorded the need for follow-up by the facility's physician. A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): ""Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated."" -- 2. A review of the resident's treatment administration records (TARs), medication administration records (MARs), and physician orders [REDACTED]. - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - ""Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing."" The order was discontinued at 1:50 p.m. on 05/27/11. - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml (""Instructions: Great toe on left foot""); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. According to the physician order [REDACTED]. - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for ""UTI"" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. - Order Date: 06/02/11 at 5:00 p.m. - ""TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed."" - Order Date: 06/04/11 - ""... D/C Skin prep to tip of (lt) gt (great) toe. ..."" - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml (""Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. -- 3. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11. There was no entry to correspond with notification of the attending physician of the podiatrist ' s findings on 05/12/11, no entry to correspond with notification of the family of the order for [MEDICATION NAME] and a dry dressing on 05/14/11, and no entry to reflect nursing staff notified the resident's family of a verbal order from the physician for Keflex to treat ""possible infection / [MEDICAL CONDITION]"" of the left great toe on the evening of 05/19/11. - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): ""05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..."" There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding. - An entry, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area. - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. There were no entries in the nursing progress notes to reflect the resident's family was notified that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infected left great toe, had been discontinued. - On 06/03/11 at 2:30 a.m., Employee #30 (an LPN) recorded: ""... resident has new order for arterial ultrasound of left lower leg stat. ..."" On 06/03/11 at 6:21 p.m., Employee #11 recorded: ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" On 06/05/11 at 8:23 a.m., Employee #11 recorded: ""Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t (due to) his overall condition. ..."" - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): ""... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... "" Documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; ""awaiting delivery from pharmacy"" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): ""Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11."" -- In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. (See also citation at F224.) .",2014-12-01
10787,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,225,D,1,0,PBEB12,". Based on a review of grievance / complaints received by the facility since 09/24/11 and staff interview, the facility failed to immediately report allegations of abuse and neglect to all State officials in accordance with State law for two (2) of six (6) sampled residents. The medical power of attorney representative (MPOA) for Resident #7 reported to staff, on 09/28/11, various concerns including Resident #7 not getting enough to eat and not receiving her snacks, not receiving enough fluids, and her hair was not being combed. This grievance contained allegations of neglect that were not immediately reported to State officials. The MPOA of Resident #8 reported to staff, on 10/31/11, various concerns including that staff did not pay attention to Resident #8, staff was not bringing the resident out of her room, that a nursing assistant told the resident she should be in bed asleep, and that her chair alarm was unplugged. These allegations of neglect were not immediately reported to State officials in accordance with State law. Resident identifiers: #7 and #8. Facility census: 57. Findings include: a) Resident #7 Review of the resident grievance / complaint forms received by the facility since 09/24/11 found the following concerns expressed by the MPOA of Resident #7, as recorded on the form by the director of nursing (DON) on 09/28/11, in the section with the heading ""Describe the nature of the grievance / complaint (be specific). ..."" (quoted as written): ""Concerned not getting enough to eat and not receiving her snacks. Had episode of unresponsiveness a couple of weeks ago and was concerned she was dehydrated."" On the associated resident grievance / complaint investigation form dated 09/28/11, the DON recorded the following in the section with the heading ""Describe the incident as provided by the resident / individual"" (quoted as written): ""Concerned resident was not receiving enough fluids. B/P (blood pressure) was low and had incident of unresponsiveness. Concerned snacks are not being given and resident's hair was not combed."" On this same form, the DON checked ""No"" in response to the following questions: - ""Is this incident a form of abuse or neglect?"" - ""Reportable to NA (Nurse Aide) Registry?"" - ""Reportable to OHFLAC (State survey agency)?"" During an interview with the DON (Employee #5) and the assistant administrator (Employee #37) on 11/03/11 at 10:30 a.m., they confirmed these allegations had not been viewed as neglect and had not been immediately reported to the State officials as required by law. According to 42 CFR 488.301: ""Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."" - b) Resident #8 Review of the resident grievance / complaint forms received by the facility since 09/24/11 found the following concerns expressed by the MPOA of Resident #8 as recorded on the form (which was not signed but which identified the grievance as received on 10/31/11) in the section with the heading ""Describe the nature of the grievance / complaint (be specific). ..."" (quoted as written): ""(Name of daughter of Resident #8) expressed several concerns regarding care issues involving her mother, (Resident #8). She stated her mother has told her no one pays attention to her and (name of daughter) is concerned over her (arrow pointing to right)..."" On the associated resident grievance / complaint investigation form dated 10/31/11, the DON recorded the following continuation of the concern in the section with the heading ""Describe the incident as provided by the resident / individual"" (quoted as written): ""... mother not coming out of her room. A CNA (certified nursing assistant) told (Resident #8) over the week-end she should be in bed and asleep. ... Other issues involved ... items out of reach, chair alarm unplugged. ..."" On this same form, the DON checked ""No"" in response to the following questions: - ""Is this incident a form of abuse or neglect?"" - ""Reportable to NA Registry?"" - ""Reportable to OHFLAC?"" On 11/03/11 at 8:30 a.m., Employee #37 presented a statement which stated the nursing home had contacted the temporary staffing agency and requested the nursing assistant not be sent back to this nursing home due to complaints and unprofessionalism. During an interview with the DON and assistant administrator on 11/03/11 at 10:30 a.m., they confirmed these allegations had not been viewed as abuse or neglect and had not been reported to the State agencies as required by law. According to 42 CFR 488.301: ""Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."" .",2014-12-01
10788,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,224,G,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to assess / monitor and obtain timely medical intervention for one (1) of seven (7) sampled residents, resulting in a delay in identification and treatment of [REDACTED]. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. The facility did not obtain an order to continue the application of this topical antibiotic to the toe until 05/14/11, and there was no evidence the family was informed of the blister or the topical antibiotic ordered to treat this area. There was no evidence to reflect the nursing staff routinely assessed / monitored the status of this blister after the daily application of a topical antibiotic and a dressing were ordered on [DATE], as evidence by a lack of any nursing progress notes from 04/22/11 until 05/19/11. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle; however, receipt of the order for a topical antibiotic received on 05/14/11 and an acknowledgement of the family's concerns about the resident's left foot were not recorded in any nursing progress notes until a late entry was made on 07/08/11. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose of Keflex was not administered until 6:00 a.m. on 05/20/11, and the 6:00 p.m. dose on 05/26/11 was skipped due ""awaiting delivery from pharmacy"". After the Keflex was started, there remained a lack of evidence to reflect that nursing staff was routinely assessing / monitoring the status of this area as well as the resident's response to the treatment, as evidenced by no description of resident's left great toe in any nursing notes until a late entry was recorded by a nurse on 05/22/11 (with only periodic descriptions recorded thereafter) and the absence of any wound assessment and progress review records describing the affected area. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be ""blackish / brownish"" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. After this discoloration to the tip of the toe was noted, there again remained a lack of evidence to reflect the nursing staff was routinely assessing / monitoring the status of this area, as the documentation began to focus on the resident's respiratory status. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to ""awaiting delivery from pharmacy"". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. According to his comprehensive annual minimum data set assessment (MDS) with an assessment reference date (ARD) of 12/16/10, he was alert, but his score of ""3"" on the Brief Interview for Mental Status indicated his cognitive skills were severely impaired. In Section G, the assessor noted he was totally dependent on staff for the performance of all activities of daily living (ADLs). In Section I, his active [DIAGNOSES REDACTED]. Other health conditions included pain almost constantly and shortness of breath when lying down. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 03/10/11, he remained dependent on staff for the performance of all ADLs. In Section I, the assessor did not indicate the presence of any new [DIAGNOSES REDACTED]. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 06/02/11, he remained dependent on staff for the performance of all ADLs. In Section I, his active [DIAGNOSES REDACTED]. In Section M, he was noted to have one (1) Stage 2 pressure ulcer (with the oldest Stage 2 ulcer having been identified on 05/20/11) and one (1) Stage 3 pressure ulcer (measuring 3.0 cm x 0.8 cm). The assessor also noted the presence of an infection of the foot (e.g., [MEDICAL CONDITION]). Subsequently, the facility completed and electronically submitted a comprehensive MDS for a significant change in status with an ARD of 07/06/11, in which the assessor noted he remained dependent on staff for the performance of all ADLs, his active [DIAGNOSES REDACTED]. -- 2. According to an article about gangrene found on Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health: ""Gangrene is the death of tissue in part of the body. ""Gangrene happens when a body part loses its blood supply. This may happen from injury, an infection, or other causes. You have a higher risk for gangrene if you have: - A serious injury - Blood vessel disease (such as [MEDICAL CONDITION], also called hardening of the arteries, in your arms or legs) - Diabetes - Suppressed immune system (for example, [MEDICAL CONDITIONS]) - Surgery ""Symptoms ""The symptoms depend on the location and cause of the gangrene. If the skin is involved, or the gangrene is close to the skin, the symptoms may include: - Discoloration (blue or black if skin is affected; red or bronze if the affected area is beneath the skin) - Foul-smelling discharge - Loss of feeling in the area (which may happen after severe pain in the area) ""Treatment ""Gangrene requires urgent evaluation and treatment. In general, dead tissue should be removed to allow healing of the surrounding living tissue and prevent further infection. Depending on the area that has the gangrene, the person's overall condition, and the cause of the gangrene, treatment may include: - Amputating the body part that has gangrene - An emergency operation to find and remove dead tissue - An operation to improve blood supply to the area - Antibiotics - Repeated operations to remove dead tissue (debridement) - Treatment in the intensive care unit (for severely ill patients) ""When to Contact a Medical Professional ""Call your doctor immediately if: - A wound does not heal or there are frequent sores in an area - An area of your skin turns blue or black - There is foul-smelling discharge from any wound on your body - You have persistent, unexplained pain in an area - You have persistent, unexplained fever ""Prevention ""Gangrene may be prevented if it is treated before the tissue damage is irreversible. Wounds should be treated properly and watched carefully for signs of infection (such as spreading redness, swelling, or drainage) or failure to heal."" (URL for this article is ) -- 3. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): ""Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated."" -- 4. A review of the resident's physician orders, treatment administration records (TARs), and medication administration records (MARs) found the following: - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - ""Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing."" The order was discontinued at 1:50 p.m. on 05/27/11. Nurses' initials on the TAR indicated this treatment was completed daily from 05/14/11 through 05/26/11. Documentation on the physician order [REDACTED]. Reeval (re-evaluate). Area is unstageable."" - - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml (""Instructions: Great toe on left foot""); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. Nurses' initials on the MAR indicated [REDACTED]. Documentation indicated a dose was missed at 6:00 p.m. on 05/26/11 due to ""awaiting delivery from pharmacy"". According to the physician order [REDACTED]. - - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for ""UTI"" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. Nurses' initials on the MAR indicated [REDACTED]. - Order Date: 06/02/11 at 5:00 p.m. - ""TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed."" - Order Date: 06/04/11 - ""... D/C Skin prep to tip of (lt) gt (great) toe. ..."" - - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml (""Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]""awaiting delivery from pharmacy""), but no reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (Note: There was no evidence in the nursing progress notes for this time period to reflect that nursing staff notified the physician and/or the family that the resident did not receive all twenty-eight (28) doses of this 7-day course of antibiotics.) -- 5. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11, and no entries made on 05/19/11 addressed the status of the resident's left great toe. (Note: There was no contemporaneous entry to correspond with the receipt of an order for [REDACTED]. of this new medication order or the reason for its use.) - An entry, with no date or time recorded but signed by a registered nurse (RN - Employee #11) on 05/20/11, stated (quoted as typed): ""Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..."" - An entry, with no date or time recorded but signed by a licensed practical nurse (LPN - Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 (Name of attending physician) to see resident this shift, no new orders. Progress note written."" - An entry, with no date or time recorded but signed by Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 Resident alert and verbal w/ (with) intermittent confusion observed, able to make some needs known to staff. Resident started Keflex Oral Suspension 250 MG/ML 500MG PO (by mouth) TID (three-times-daily) related to great toe on left foot. No s/s (signs / symptoms) of adverse reaction to medication observed at this time. ..."" (Note: There was no description of the affected area, and the frequency at which the antibiotic Keflex was to be given was four (4) times daily, not three (3) times daily as stated in this note.) - An entry, with no time recorded but signed by Employee #40 (an LPN) on 05/22/11, stated (quoted as typed): ""05/21/11 Late entry Vital signs ... Resident remains on Keflex elixer 250mg/5cc 10cc po (by mouth) administered per md orders qid (four-times-daily). No s/s of adverse reaction noted. Keflex administered for left great toe infection. Resident left great toe red and warm with slight [MEDICAL CONDITION] noted. No c/o pain offered. Dsg (dressing) changed per md orders. Call bell within reach."" (Note: This was the first description of the resident's left great toe to have been documented in the record since the podiatry consult dated 05/12/11.) - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): ""05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..."" (Note: There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding.) - Subsequent entries stated the following: - 05/22/11 at 2317 (11:17 p.m.) by Employee #61 (an RN) - ""... continues to receive Keflex ..."" (No description of the affected toe was provided.) - 05/23/11 at 0318 (3:18 a.m.) by Employee #61 - ""... Resident continues to receive Keflex ..."" (No description of the affected toe was provided.) - 05/23/11 at 1024 (10:24 a.m.) by Employee #40 - ""... Resident continues on Keflex ... Left great toe is discolored red with small amount of yellow drainage noted ..."" - 05/24/11 (no time recorded) by Employee #51 (an LPN) - ""... He is currently on Keflex related to infected toe ..."" (No description of the affected toe was provided.) - An entry, with no date or time recorded but signed by Employee #62 (an RN) on 05/24/11 - ""... Resident taking Keflex for [MEDICAL CONDITION] in L foot and L great toe. ..."" (No description of the affected foot or toe was provided.) - Further entries reiterated that Resident #14 was receiving Keflex for an infected left great toe, with no descriptions of the affected area provided. - The next entry that provided a description of the affected area, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" (Note: There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area.) - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. (Note: There were no entries in the nursing progress notes to reflect the resident's family was notified of the change in the status of the resident's great toe or that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infection toe, had been discontinued.) - After the [MEDICATION NAME] was started, nursing documentation began to focus on the resident's respiratory status, and documentation of the status of the resident's left great toe diminished in frequency with the following entries noted (all quoted as typed): - 05/28/11 at 11:52 a.m. by Employee #62 - ""... Wound to left great toe, skin prep every day applied. ..."" - 05/29/11 at 3:17 p.m. by Employee #11 - ""... Res has [MEDICAL CONDITIONS], and the area to lt grt toe could be d/t (due to) that disorder. The area is measuring 0.8cmx2cm and is a dark purplish/brownish area. No odor or drainage noted. The tx of skin prep continues as ordered. ..."" - 06/03/11 at 2:30 a.m. by Employee #30 (an LPN) - ""... resident has new order for arterial ultrasound of left lower leg stat. ..."" - 06/03/11 at 6:21 p.m. by Employee #11 - ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" (Note: The resident was receiving [MEDICATION NAME] to treat an upper respiratory infection; contrary to what was stated in this note, the resident was not on any antibiotics at this time to treat the infection of his left great toe.) - 06/04/11 at 12:02 a.m. by Employee #51 - ""... He, Finished his [MEDICATION NAME] for the URI. His right Great toe is black in color and no drainage at this time. ..."" (Note: This entry identified his right (not his left) great toe as the site of the infection.) - 06/04/11 at 6:35 p.m. by Employee #11 - ""Res is on [MEDICATION NAME] d/t an infiltrate ... The wound to his lt grt toe remains black and is warm to touch, no odor or drainage noted. It is slightly reddened around the outside of the nail bed. ..."" (Note: This entry identified that he was still receiving [MEDICATION NAME] when the previous entry stated he had taken his last dose of this antibiotic.) - 06/05/11 at 8:23 a.m. by Employee #11 - ""Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t his overall condition. ..."" - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): ""... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... "" As noted above, documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; ""awaiting delivery from pharmacy"" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): ""Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11."" -- 6. physician progress notes [REDACTED]. Review of the physician's progress notes revealed an entry dated 04/14/11 which contained no mention of any problems with the resident's feet. The next consecutive entry, dated 05/20/11, also made no mention of any problems with the resident's feet. The next consecutive entry, dated 05/26/11, noted the resident was on Keflex for [MEDICAL CONDITION] of the left great toe and identified a plan to change the Keflex to [MEDICATION NAME] to treat an upper respiratory infection. The next consecutive entry, dated 06/02/11, noted the physician had been asked to re-evaluate the resident's left great toe. The tip of the toe was black. The physician noted, ""... Gangrene (L) great toe - failed antibiotics. ..."" -- 7. Review of the wound assessment and progress review forms on Resident #14's medical record found no such records were initiated to track the status of the blister, which was intact when identified by the podiatrist on the resident's left great toe on 05/12/11. -- 8. Care Plans Review of the resident's care plans found an episodic care plan, dated 05/20/11, stating (quoted as written): Problem: ""Infection great left toe. Goal: ""Will resolve during the next 14 days."" Approaches: ""(1) Antibiotic as ordered. (2) Treatment as ordered. (3) Monitor for improvement or decline of area. Notify MD as needed."" This care plan has a ""D/C (Discontinuation) Date"" of 05/27/11. - There was no evidence that an episodic care plan was developed to address the resident's left great toe on 05/12/11, when the podiatrist identified and treated the blister, or on 05/14/11, when the attending physician ordered the daily application of a topical antibiotic and a dry dressing to the resident's left great toe. The facility also failed to review / revise the resident's care plan to address the need for on-going monitoring of the resident's left great toe and left foot between the date the 05/20/11 episodic care plan was discontinued on 05/27/11 and when the comprehensive care plan was updated on 06/14/11, to note the presence of gangrene and the initiation of comfort measures only. -- 9. In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. .",2014-12-01
10789,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,425,D,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure an antibiotic was available for administration in accordance with physician orders [REDACTED]. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to ""awaiting delivery from pharmacy"". When the first three (3) scheduled doses of the medication were not available for administration, the facility also failed to adjust the stop date for this antibiotic to ensure all twenty-eight (28) doses were administered. As a result, the resident only received twenty-five (25) doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. A review of the resident's physician orders [REDACTED]. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]""awaiting delivery from pharmacy""). No reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. When the first three (3) scheduled doses of the medication were not available for administration, the facility failed to adjust the stop date for this antibiotic to ensure all twenty-eight (28) doses were administered. As a result, the resident only received twenty-five (25) doses. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (See also citation at F224.) .",2014-12-01
10790,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,514,E,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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, for one (1) of seven (7) sampled residents, to maintain clinical records in accordance with accepted professional standards and practices that ensure each resident's record is complete and accurately documented. The extent of the deficient practice affecting Resident #14 demonstrated a pattern of non-compliance with this requirement. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) -- 2. Lack of documentation related to an acute change in condition and change in treatment There were no entries from 05/12/11 through 05/19/11, during which time: - On 05/12/11, the podiatrist identified and treated a blister to the left great toe and recommended follow-up treatment by the facility's physician; - On 05/14/11, the attending physician ordered daily applications of [MEDICATION NAME] (a topical antibiotic) and a dry dressing to the left great toe; and - On 05/19/11, the attending physician ordered Keflex (an oral antibiotic) four-times-daily for ""possible infection / [MEDICAL CONDITION]"" of the left great toe. There was no contemporaneous entry in the nursing progress notes to correspond with receipt of an order for [REDACTED]. There was no contemporaneous entry in the nursing progress notes to correspond with receipt of a verbal order for Keflex to on the evening of 05/19/11, and there was no entry to reflect nursing staff notified the resident's family of this new medication order or the reason for its use. Even after the Keflex was started on 05/20/11, there was an absence of documentation to reflect routine assessment / monitoring of the status of the resident's left great toe and the resident's response to treatment. On 06/02/11, the physician determined the left great toe had become gangrenous. (See citation at F224 for details.) - According to the AHIMA LTC documentation guidelines: ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #14's health status in accordance with professional standards of practice. - In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE]. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. -- 3. Entries without Dates and/or Times Various entries in the nursing progress notes did not contain dates and times to indicate when the events described in the entries occurred; in many cases, the only evidence of a date was the date when the nurse signed the entry. For example: - An entry, signed by a registered nurse (RN - Employee #11) on 05/20/11, stated (quoted as typed): ""Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..."" - An entry, signed by a licensed practical nurse (LPN - Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 (Name of attending physician) to see resident this shift, no new orders. Progress note written."" - An entry, with no date or time recorded but signed by Employee #62 (an RN) on 05/24/11 - ""... Resident taking Keflex for [MEDICAL CONDITION] in L foot and L great toe. ..."" - An entry, with no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" -- 4. Late Entries Nursing progress note entries describing events that occurred prior to the date / time the nurse signed the entry were not properly identified as ""late"" entries. For example: - An entry, with no date or time recorded but signed by Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 Resident alert and verbal w/ (with) intermittent confusion observed, able to make some needs known to staff. Resident started Keflex Oral Suspension 250 MG/ML 500MG PO (by mouth) TID (three-times-daily) related to great toe on left foot. No s/s (signs / symptoms) of adverse reaction to medication observed at this time. ..."" This entry indicated it referred to events that occurred on the preceding day, but it was not identified as a ""late entry"", nor was a time recorded to indicate when the events occurred on 05/20/11, nor was a time recorded to indicate when the entry was made in the record on 05/21/11. Note: This entry also contained inaccurate information; the frequency at which the antibiotic Keflex was to be given was four (4) times daily, not three (3) times daily as stated in this note. - One (1) late entry, with no time recorded but signed by Employee #40 (an LPN) on 05/22/11, stated (quoted as typed): ""05/21/11 Late entry Vital signs ... Resident remains on Keflex elixer 250mg/5cc 10cc po (by mouth) administered per md orders qid (four-times-daily). No s/s of adverse reaction noted. Keflex administered for left great toe infection. Resident left great toe red and warm with slight [MEDICAL CONDITION] noted. No c/o pain offered. Dsg (dressing) changed per md orders. Call bell within reach."" There was a time recorded to indicate when the events occurred on 05/21/11, nor was a time recorded to indicate when the entry was made in the record on 05/22/11. - One (1) late entry made by Employee #62, dated 07/08/11 at 5:11 p.m., recorded events that were said to have occurred six (6) weeks earlier (quoted as typed): ""Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11."" - According to the AHIMA LTC documentation guidelines: ""5.3.2.1. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ... ""When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes."" The late entry recorded by Employee #62 was not entered into Resident #14's record as soon as possible. Instead, it was recorded greater than six (6) weeks after the events described therein occurred. This significant delay in recording the late entry calls into question the reliability of its contents. -- 5. Errors in Content Various nursing progress note entries also contained inaccurate information. For example: - On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. On the physician order [REDACTED]. - On 06/03/11 at 6:21 p.m. by Employee #11 - ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" The resident was receiving [MEDICATION NAME] to treat an upper respiratory infection; contrary to what was stated in this note, the resident was not on any antibiotics at this time to treat the infection of his left great toe. - On 06/04/11 at 12:02 a.m. by Employee #51 - ""... He, Finished his [MEDICATION NAME] for the URI. His right Great toe is black in color and no drainage at this time. ..."" This entry identified his right (not his left) great toe as the site of the infection. - On 06/04/11 at 6:35 p.m. by Employee #11 - ""Res is on [MEDICATION NAME] d/t an infiltrate ... The wound to his lt grt toe remains black and is warm to touch, no odor or drainage noted. It is slightly reddened around the outside of the nail bed. ..."" This entry identified that he was still receiving [MEDICATION NAME] when the previous entry stated he had taken his last dose of this antibiotic. -- 6. Transcription Error on Medication Administration Record [REDACTED] A review of the resident's physician orders [REDACTED]. Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection), not a ""UTI"". -- 7. Failure to Document Reason for Medication Omission A review of the resident's physician orders [REDACTED]. Nurses' initials on the MAR indicated [REDACTED]. No doses were administered at 6:00 p.m. on 06/13/11 or at 12:00 a.m. and 6:00 a.m. on 06/14/11. Documentation on the MAR indicated [REDACTED]""awaiting delivery from pharmacy""). No reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11.",2014-12-01
10791,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,280,D,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to review and revise the care plan of one (1) of seven (7) sampled residents who experienced an acute change in condition with resultant changes in treatment. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. On 05/14/11, the attending physician ordered the application of a topical antibiotic and a dressing to the resident's left great toe, but no episodic care plan was developed to address this. On 05/19/11, the attending physician ordered an oral antibiotic (Keflex) four-times-daily to treat ""possible infection / [MEDICAL CONDITION]"" of the left great toe and foot. An episodic care plan was developed to address an infection to the left great on 05/20/11; this care plan had a discontinuation date of 05/27/11. The resident subsequently developed gangrene (which was diagnosed on [DATE]), and the facility failed to review and revise his care plan to address the deterioration in the status of the resident's toe until 06/14/11, by which time the family asked that he be placed on comfort measures only. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. Further record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): ""Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated."" -- 2. A review of the resident's physician orders, treatment administration records (TARs), and medication administration records (MARs) found the following: - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - ""Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing."" The order was discontinued at 1:50 p.m. on 05/27/11. Documentation on the physician order [REDACTED]. Reeval (re-evaluate). Area is unstageable."" - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml (""Instructions: Great toe on left foot""); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. According to the physician order [REDACTED]. - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for ""UTI"" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. - Order Date: 06/02/11 at 5:00 p.m. - ""TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed."" - Order Date: 06/04/11 - ""... D/C Skin prep to tip of (lt) gt (great) toe. ..."" - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml (""Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. This order was discontinued at 4:00 p.m. on 06/20/11. -- 3. Review of the nursing progress notes found an entry, with no date or time recorded but signed by a registered nurse (RN - Employee #11) on 05/20/11, which stated (quoted as typed): ""Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..."" An entry, signed by a licensed practical nurse (LPN - Employee #40) on 05/22/11, stated (quoted as typed): ""05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..."" Further entries reiterated that Resident #14 was receiving Keflex for an infected left great toe. The next entry that provided a description of the affected area, which had no date or time recorded but was signed by Employee #11 (an RN) on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. After the [MEDICATION NAME] was started, nursing documentation began to focus on the resident's respiratory status, and documentation of the status of the resident's left great toe diminished in frequency with the following entries noted (all quoted as typed): - 05/28/11 at 11:52 a.m. by Employee #62 (an RN) - ""... Wound to left great toe, skin prep every day applied. ..."" - 05/29/11 at 3:17 p.m. by Employee #11 - ""... Res has [MEDICAL CONDITIONS], and the area to lt grt toe could be d/t (due to) that disorder. The area is measuring 0.8cmx2cm and is a dark purplish/brownish area. No odor or drainage noted. The tx of skin prep continues as ordered. ..."" - 06/03/11 at 2:30 a.m. by Employee #30 (an LPN) - ""... resident has new order for arterial ultrasound of left lower leg stat. ..."" - 06/03/11 at 6:21 p.m. by Employee #11 - ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" - 06/05/11 at 8:23 a.m. by Employee #11 - ""Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t his overall condition. ..."" After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): ""... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... "" -- 4. Review of the resident's care plans found an episodic care plan, dated 05/20/11, stating (quoted as written): Problem: ""Infection great left toe. Goal: ""Will resolve during the next 14 days."" Approaches: ""(1) Antibiotic as ordered. (2) Treatment as ordered. (3) Monitor for improvement or decline of area. Notify MD as needed."" This care plan has a ""D/C (Discontinuation) Date"" of 05/27/11. - There was no evidence that an episodic care plan was developed to address the resident's left great toe on 05/12/11, when the podiatrist identified and treated the blister, or on 05/14/11, when the attending physician ordered the daily application of a topical antibiotic and a dry dressing to the resident's left great toe. The facility also failed to review / revise the resident's care plan to address the need for on-going monitoring of the resident's left great toe and left foot between the date the 05/20/11 episodic care plan was discontinued on 05/27/11 and when the comprehensive care plan was updated on 06/14/11, to note the presence of gangrene and the initiation of comfort measures only. .",2014-12-01
10792,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-11-03,274,D,1,0,PBEB12,". Based on review of incident / accident reports, medical record review, and staff interview, the facility failed to provide on-going assessment for skin condition / wound treatment for two (2) of six (6) sampled residents. Resident #25 had a fluid-filled blister on the right upper thigh that required treatment, and Resident #7 sustained a laceration to the left index finger near the nail bed during nail trimming that required treatment. There was an initial nursing note at the discovery of the alterations in skin condition for Residents #25 and #7, but there was no evidence of further follow-up documentation describing the status of these wounds, which could require revision of the treatment plan. Resident identifiers: #25 and #7. Facility census: 57. Findings include: a) Resident #25 Review of incident / accident reports, on 11/02/11, disclosed a dime-sized blister had been found on the top of Resident #25's right upper thigh at 10:00 a.m. on 10/10/11. ""Resident states she doesn't know what it is but it itches."" Review of nursing notes found an entry, recorded at 2:07 p.m. on 10/10/11, stating (quoted as typed): ""Resident has a 0.3cmx0.2cm pink slightly raised blister on the top of her right thigh, that appears to have very scant amount of fluid inside. Resident states that it itches occasionally but does not hurt. Resident aware of treatment of skin prep to area ... MD made aware of skin condition and treatment."" Further review of nursing notes found no further documentation regarding the blister, such as whether it was improving or worsening or whether signs and symptoms of infection were present, which could require further physician notification and change in treatment. During an interview with the director of nursing (DON) on 11/03/11 at 11:30 a.m., the nursing notes were reviewed, and the DON agreed there had been no further documentation regarding the status of the blister. -- b) Resident #7 Review of incident / accident reports, on 11/02/11, disclosed this resident had sustained a 0.1 inch (as written on incident report) laceration to the left hand index finger near the nail bed, which had been occurred while staff was trimming the resident's finger nails. Review of nursing notes found an initial nursing note which described the laceration and treatment provided. Further review of the nursing notes found no further documentation assessing the laceration (e.g., healing status, presence of signs / symptoms of infection, etc.) which could require physician notification and change of treatment. During an interview with the DON on 11/03/11 at 11:30 a.m., the nursing notes were reviewed, and the DON agreed there had been no further documentation regarding the status of the laceration. .",2014-12-01
10793,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-11-03,279,D,1,0,PBEB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to develop an episodic care plan with measurable objectives and goals to address the treatment of [REDACTED]. Resident #25 was found to have a blister on the right upper thigh which required medical treatment, and no care plan had been developed to address this change in condition and treatment. Resident identifier: #25. Facility census: 57. Findings include: a) Resident #25 Review of incident / accident reports, on 11/02/11, disclosed a dime-sized blister had been found on the top of Resident #25's right upper thigh at 10:00 a.m. on 10/10/11. ""Resident states she doesn't know what it is but it itches."" Review of nursing notes found an entry, recorded at 2:07 p.m. on 10/10/11, stating (quoted as typed): ""Resident has a 0.3cmx0.2cm pink slightly raised blister on the top of her right thigh, that appears to have very scant amount of fluid inside. Resident states that it itches occasionally but does not hurt. Resident aware of treatment of [REDACTED]."" Further review of the medical record found no episodic care plan had been developed to address the care and treatment of [REDACTED]. Review of the facility's blister protocol, which was provided by the administrator (Employee #26) on 11/03/11, revealed Item #4 (under ""Documentation"") that an episodic care plan was to be developed. In an interview with the director of nursing (DON - Employee #5) on 11/03/11 at 11:00 a.m., she confirmed a care plan had not been developed to address the care and treatment of [REDACTED]. .",2014-12-01
10794,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-11-03,309,D,1,0,PBEB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of incident / accident reports, medical record review, staff interview, and policy review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of six (6) sampled residents. Review of incident / accident reports disclosed staff found a raised, fluid-filled blister on the top of Resident #25's right thigh on the morning of 10/10/11. An entry in the nursing notes, on 10/10/11, described the blister and stated Skin Prep had been applied as a treatment. Further record review found no further mention of the blister in the nursing notes after the initial entry was made on 10/10/11. Additionally, there was no physician's order for the application of Skin Prep to the blister, no entry on a treatment administration record to reflect the Skin Prep had been applied as stated in the nursing notes, and no episodic care plan to address the care and treatment of [REDACTED]. Resident identifier: #25. Facility census: 57. Findings include: a) Resident #25 Review of incident / accident reports, on 11/02/11, disclosed a dime-sized blister had been found on the top of Resident #25's right upper thigh at 10:00 a.m. on 10/10/11. ""Resident states she doesn't know what it is but it itches."" Review of nursing notes found an entry, recorded at 2:07 p.m. on 10/10/11, stating (quoted as typed): ""Resident has a 0.3cmx0.2cm pink slightly raised blister on the top of her right thigh, that appears to have very scant amount of fluid inside. Resident states that it itches occasionally but does not hurt. Resident aware of treatment of [REDACTED]."" - Review of the medical record found no episodic care plan had been developed to address the care and treatment of [REDACTED]. In an interview with the director of nursing (DON) on 11/03/11 at 11:00 a.m., she confirmed a care plan had not been developed to address the care and treatment of [REDACTED]. - Further review of nursing notes found no further documentation regarding the blister, such as whether it was improving or worsening or whether signs and symptoms of infection were present, which could require further physician notification and change in treatment. During an interview with the DON on 11/03/11 at 11:30 a.m., the nursing notes were reviewed, and the DON agreed there had been no further documentation regarding the status of the blister. - Review of the resident's physician orders found no order had been written for the use of Skin Prep, including how often Skin Prep was to be applied and the duration of the treatment. Review of the TARs for this resident found no physician's order on a TAR to apply the treatment; consequently, there was no documentation on a TAR by licensed nurses to indicate when the Skin Prep was first applied and how often it was applied thereafter. - During an interview on 11/03/11 at 2:50 p.m., the DON revealed the facility's blister protocol had been used, which called for the use of Skin Prep. Review of the blister protocol found the follow steps to be taken upon discovery of an intact blister (quoted as typed): ""1. Cleanse wound with wound cleanser; pat dry ""2. Apply skin prep ""3. Leave open to air ""4. Documentation ""a. Order ""b. Transcribe Order ""c. Document treatment on Treatment Administration Record ""d. Inititate an Episodic CarePlan ""e. Notification of patient/family/HCDM"" The DON agreed the blister protocol had not been followed. There was no order written for the use of Skin Prep, no record of the application of the Skin Prep on the TAR, and no episodic care plan. .",2014-12-01
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
10798,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,225,D,0,1,7F5X11,"Based on staff interview and review of the facility's personnel files, the facility failed to obtain nurse aide registry checks for two (2) of five (5) randomly chosen newly hired employees, and failed to obtain a criminal background check for one (1) of five (5) randomly chosen newly hired employees. Employee identifiers: #54, #99, and #41. Facility census: 86. Findings include: a) Employees #54 and #99 Review of sampled personnel files, on 09/24/09, revealed a registered nurse (Employees #54) and a housekeeper (Employee #99) were hired within the preceding five (5) months, and neither file contained evidence to reflect the facility had checked the WV nurse aide registry for findings against them of resident abuse / neglect. The office manager (Employee #40) reviewed personnel files at this time and confirmed there was nothing in the files to indicate State nurse aide registry checks had been completed prior to or upon initial hire for either of these employees. The director of nursing and administrator were informed of these findings on 09/24/09. b) Employee #41 Review of sampled personnel files, on 09/24/09, revealed a dietary staff member (Employee #41) was recently hired, but there was no evidence to reflect the facility had conducted a criminal background check on her. Employee #40 reviewed personnel files at this time and confirmed there was nothing in the files to indicate a criminal background check had been initiated upon initial hire of this employee. The director of nursing and administrator were informed of this finding on 09/24/09. .",2014-12-01
10799,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,203,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and a copy of the current information provided to residents at the time of discharge or transfer from the facility, the facility failed to provide accurate information to residents and their responsible parties upon transfer / discharge. Under the section informing the resident / responsible party of the State agency to which an appeal of a transfer / discharge decision could be made, the information sheet listed two (2) State agencies that were not appropriate. Additionally, one (1) resident who was transferred to another facility was not provided with the required notice. Three (3) of eighteen (18) residents on the sample were affected. Resident identifiers: #6, #87, #88, and any resident who was provided a copy of the notice when transferred or discharged . Facility census: 86. Findings include: a) Resident #6 Resident #6 was discharged during the course of the survey. Additional review of her medical record after her discharge to home found the notice of transfer form, dated 09/22/09, informed the resident she could appeal the discharge or transfer to the regional ombudsman or the State ombudsman, in addition to the DHHR Office of the Inspector General. Only the latter agency has the authority to hear such appeals. This prompted a review of the information provided at the time of discharge / transfer, to ascertain whether this same inaccurate information was being provided to all residents. The copy of the form received from the administrator, on 09/25/09, was the same as that provided to Resident #6. b) Resident #87 Closed medical record review, on 09/24/09, revealed this resident was admitted on [DATE]. On 07/18/09, the resident was discharged home. The advocacy information, provided to the resident upon discharge, noted the resident could appeal the discharge to the State ombudsman and to the regional ombudsman. This was incorrect information, as the only State agency to whom a resident may appeal a discharge discharge is the DHHR Office of Inspector General. c) Resident #88 Review of closed medical record revealed Resident #88 was discharged to another facility, but there was no evidence that he or his representative was given an appeals notice upon discharge. The current director of nursing (who was not employed at the facility at the time of this resident's discharge) was informed, on 09/25/09 at approximately 9:30 a.m., of the absence of an appeals notice for Resident #88's discharge. No appeals notice was produced prior to survey exit. .",2014-12-01
10800,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,522,C,0,1,7F5X11,"Based on interview and e-mail correspondence with a representative of the Office of Health Facility Licensure and Certification (OHFLAC) and information learned at a sister facility, it was determined the facility had not provided written notice to the State agency responsible for licensing the facility at the time of a change of the facility's director of nursing. All residents had the potential to be affected. Facility census: 86. Findings include: a) During survey at a sister facility in the latter part of August 2009, a staff member had commented that Employee #44 was now the director of nursing (DON) at Marmet Center. Another surveyor had also heard of the change of DON at the facility. Prior to beginning the survey of this facility, an e-mail had been sent to OHFLAC to ascertain who the current administrator and DON were. The return e-mail named another individual as the DON. The office had not received notification of the change in DONs. A representative of OHFLAC contacted the facility and learned the DON was now Employee #44, but notification had not been made to OHFLAC at the time of the change as required.",2014-12-01
10801,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,323,E,0,1,7F5X11,"Based on observations and a staff member's comment, the facility failed to ensure the resident environment was as accident-free as possible. The gate into the nurses' station did not have a closure device to prevent it from swinging open into the hall. All mobile residents had the potential to be affected. Facility census: 86. Findings include: a) Throughout the survey, observation found that, as staff entered and exited the nurses' station, they would push the gate closed. However, if too much force was used, the gate would swing open again. On one (1) occasion, a staff member was overheard commenting about the magnet on the door not being strong enough to hold the door closed. Examination of the closure device noted it was a small magnet. If the gate were not closed far enough, it was subject to swing open. Likewise, if the door were closed too firmly, it would swing open again. At times, observation found residents near the door (in wheelchairs or ambulating) when it swung open, creating a potential for injury. .",2014-12-01
10802,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,441,F,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of facility policies and procedures, the facility failed to develop and implement an infection control program that ensured staff employed appropriate infection control practices when rendering care to residents. Staff did not employ handwashing in accordance with facility policy and the Centers for Disease Control and Prevention (CDC) guidelines; a nurse's hair came in contact with the resident's bed while she was providing a treatment; nonsterile gloves used during treatments were not handled in a manner to prevent introduction of non-resident organisms into wounds / eyes; a cut flower arrangement overhung a box of nonsterile gloves; residents were observed with the tubing of their indwelling urinary catheters dragging the floor; plastic spoons stored in a container on a medication cart were not placed in the container to prevent contact with the bowl when retrieving a spoon; and open containers of thickened water were not labeled with the date and time they were opened and/or refrigerated. These practices had the potential to affect all residents residing in the facility. Facility census: 86. Findings include: a) Resident #76 After providing assistance to this resident, a licensed practical nurse (LPN - Employee #91) washed her hands at the sink. She used paper towels to dry her hands, then turned off the water with paper towels. After turning off the faucet, she used the same paper towels to further dry her hands. This resulted in her hands being recontaminated. b) Resident #30 On 09/24/09, in mid-morning, a registered nurse (RN - Employee #23) was observed providing a treatment to this resident. As she worked, her hair dragged on the sheets near the resident's hips. This created a potential for introduction of microorganisms from the nurse's hair to the resident's bed and the resident's bed to her hair, which might then be transferred to other residents. Also, a nursing assistant (Employee #35) obtained a pair of nonsterile gloves to wear while assisting the nurse. She put the gloves in her pocket, washed her hands, then donned the gloves. By putting the gloves in her pocket, she defeated the purpose of washing her hands. The gloves would be subject to contamination by the same microorganisms that had been on the employee's hands prior to washing. c) Resident #81 On 09/22/09, at 3:20 p.m., two (2) nursing assistants (Employees #80 and #83) were observed washing their hands after assisting this resident back to bed. During this process, it was necessary to move the resident's Foley urinary catheter tubing and drainage bag from his wheelchair to the bed also. While repositioning the drainage bag, it was held approximately one (1) foot above the level of the resident's bladder. Urine in the drainage tubing could be seen flowing back toward the resident's bladder. Additionally, while the resident had been up in his wheelchair and out in the hallway, the catheter drainage tubing had been dragging on the floor. After completing the transfer of the resident and the urine drainage bag, the nursing assistants washed their hands at the sink. Employee #80 washed her hands, then turned the faucet off with her bare hands. Employee #83 only washed her hands for approximately four (4) seconds. Also during this process, the LPN (Employee #103) obtained supplies to provide a dressing change to the resident's foot. She placed items, including nonsterile gloves, into a clean translucent trash bag. This resulted in the gloves coming in contact with the other supplies in the bag. Additionally, trash bags are not acceptable for food service due to oils on the surface of the bag. Consequently, this might also affect wound care. At this time, the resident's daughter requested he be given pain medication which required delaying the treatment for [REDACTED]. At 4:45 p.m., Employee #103 retrieved new supplies from the treatment cart in the same fashion as earlier. After placing the supplies on an overbed table (on a barrier), the nurse donned gloves and opened the dressing supplies. She then sprayed the wound with [MEDICATION NAME] to clean it, and dried the area while wearing the same gloves. This created a potential for transfer of microorganisms, that were on the packaging of the dressing supplies that had been in the treatment cart, to the resident's wound. d) Resident #30 On 09/24/09, in mid-afternoon, this resident was observed while in bed. Employee #35 assisted Employee #103 to position the resident for a treatment. Prior to the treatment and afterward, the resident's Foley urinary catheter drainage tubing was observed lying on the floor. e) Resident #48 This resident was observed wheeling herself about the hallways. Her urinary catheter drainage tubing dragged the floor underneath her chair as she traveled about. This was observed from at 1:00 p.m. to 2:30 p.m. and again from 9:45 a.m. to 10:15 a.m. on 09/25/09. f) Resident # 21 On 09/24/09, during afternoon medication pass observations, Employee #91 administered eye drops to this resident. She placed gloves in her pocket and entered the room. She started to don the gloves, then put them back in her pocket and washed her hands. She pulled the gloves from her pocket, donned them, then administered the eye drops to the resident's right eye. The nurse's pocket would have been contaminated by repeated placing her hands in and out of her pockets during the course of the day. The nurse washed her hands prior to administering the eye drops to the resident's left eye. She retrieved a new pair of gloves from a box of gloves on a bedside table on which a cut flower arrangement sat. The flowers hung over the box of gloves. Cut flowers are known to harbor bacteria such as Staphylococcus aureus. g) Resident #7 On 09/24/09 at approximately 1:40 p.m., during afternoon medication administration observations, Employee #91 used thickened water from the medication cart with which to give the resident his medications. The nurse said the resident hated cold water. The box of water was felt and found to be at room temperature. There was no date to indicate when the box had been opened. At 4:15 p.m., the 64 ounce box of thickened water was still on the cart for B and C halls. According to the manufacturer's label, the water was to be refrigerated or stored at ambient temperature for eight (8) hours after opening. A white box was provided on the top of the container, so the container could be dated and timed when opened. Another open container of the thickened water was found in the hall on a cart. It, too, was at room temperature and was not labeled with the date and time it was opened. This was discussed with the director of nursing at approximately 5:00 p.m. on 09/24/09. h) During the afternoon medication pass, as Employee #91 retrieved a spoon from a container on the medication cart (for B and C halls), it was noted some of the spoons were stored with the bowl of the spoon down and some with the bowl up. The container was full, and it was difficult to retrieve a spoon by the handle without having contact with the spoons stored with the bowl upward. The medication cart for the A and D halls was observed. All of the plastic spoons were stored with the bowls down. At 4:15 p.m., the container on the cart for B and C halls was again observed. All of the spoons were stored with the bowl downward. i) During observation of meal preparation at 10:55 a.m. on 09/23/09, a dietary staff member (Employee #69) was observed washing her hands. She washed her hands, dried them, then turned off the faucets with paper towels. After turning off the faucets, she continued drying her hands and arms with the towels she had used to turn off the faucets. This practice contaminated her hands. At 11:10 a.m., a second dietary staff member (Employee #66) was observed washing her hands. She contaminated her hands in the same manner as Employee #69. These practices had the potential to affect all residents who received nourishment from the dietary department. .",2014-12-01
10803,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,514,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure medical records were complete and accurate. The monthly recapitulation of physician orders [REDACTED]. A POST form found in one (1) resident's medical record was blank except for the physician's signature and date. Resident identifiers: #48, #49, and #6. Facility census: 86. Findings include: a) Resident #48 The POST form in the resident's medical record was blank other than having been signed and dated by the physician. The form was dated 07/31/09. The recapitulation of physician's orders [REDACTED]. During an interview with a a licensed practical nurse (LPN - Employee #37) regarding another resident's code status on 09/25/09 at 2:15 p.m., she was asked to show where she would check for the resident's code status. She referred to the POST form in that resident's chart. In a subsequent interview, the director of nursing also said staff was to check the POST form. If a staff member were to check Resident #48's POST form, there would be a possibility that resuscitation efforts might be made since the form was incomplete. b) Resident #6 The POST form for this resident was signed by the physician on 08/17/09. The form indicated the resident was not to be resuscitated. The monthly recapitulation of physician's orders [REDACTED]. c) Resident #49 The resident's POST form indicated the resident was not to be resuscitated. The current monthly recapitulation of physician's orders [REDACTED]."" In this instance, the physician had placed his signature stamp on the recapitulation on 09/01/09 and had signed the POST form on 09/10/09. The latter would supercede the former by virtue of being the most recent order. However, if the next recapitulation were not changed, it would supercede the order of the POST form. .",2014-12-01
10804,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,152,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the rights of residents were exercised by an individual appointed in accordance with State law. One (1) resident, who been determined to lack capacity prior to admission, had a health care surrogate appointed while in the hospital. Documentation indicated some staff was aware of this; however, others were a party to completion of a medical power of attorney document (MPOA), which would not be valid as the resident had not been deemed to have the capacity to make the appointment. Additionally, the MPOA had been witnessed by two (2) facility staff members, which was prohibited by the facility's policy. Two (2) residents, who were found to have capacity, had health care decisions made by others. Three (3) of the fifteen (15) current residents on the sample were affected. Resident identifiers: #6, #81, and #46. Facility census: 86. Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. 1. Review of the resident's medical record found a document entitled ""Health Care Decision Making"" that listed the resident's representative as Individual A and noted he was the resident's health care surrogate (HCS). At the bottom of the document, ""Surrogate Decision Maker for Health Care"" was marked as being the resident's advance directive. A date of 08/17/09, initialed by Employee #58, had been entered as the date the HCS document had been obtained. A ""Physician order [REDACTED]. This form had been prepared by Employee #20, a registered nurse. This was further evidence some staff was aware the resident had previously had a health care surrogate appointed due to a determination of incapacity. 2. A copy of a ""State of West Virginia Medical Power of Attorney"" was also found in the resident's medical record. The form was dated 08/24/09 and signed by the resident. This form named Individual A as the resident's MPOA representative. There was no indication why the MPOA had been completed, given that the resident had a HCS appointed and needed only to be reviewed by the physician. 3. A ""Physician Determination of Capacity"" had been completed by the resident's physician on 08/25/09. The physician determined the resident lacked capacity to make health care decisions, because she lacked the capacity to appreciate the nature and implication of healthcare decisions. 4. To execute an MPOA, a resident must have capacity. This document had been completed, although her hospital records documented she lacked the capacity to make such an informed decision as this. Additionally, the day after it was signed, her attending physician at the facility also determined that she lacked capacity. 5. The MPOA, executed on 08/24/09, had been witnessed by facility staff - Employees #86 (the assistant director of nursing) and #89 (the food services director). The facility's policy entitled ""Health Care Decision Making"" includes: ""GHC (Genesis Health Care) staff will not act as witnesses to signing of any forms or documents concerning health care decision making .... "" 6. A copy of the HCS appointment from the hospital was found with the records the hospital had sent to the facility. There was also a ""Determination of Capacity"" form dated 08/05/09, where the physician had noted the resident demonstrated incapacity to make medical decisions based on his examination of her in the hospital. The incapacity was expected to be long term. 7. The social worker who had completed the ""Health Care Decision Making"" form (which noted the resident had a HCS) was not available. The director of nursing was asked if she was aware of what had prompted the completion of the MPOA document when the resident had a HCS from the hospital in place. She did not know why this had been done. She agreed the MPOA document would not have been valid, since the resident had determinations of incapacity before and after the MPOA document was executed. b) Resident #81 This resident's medical record contained a form entitled ""Consent for Treatment and Release of Information"". The form had the resident's name written on it and a date of 09/11/09. It was apparent this had been written by the same nurse (Employee #54) who also signed the form and dated her signature 09/11/09. The resident's MPOA representative had signed the document, which authorized medical care but also authorized disclosure of information to the resident's daughters, the resident's son, and two (2) in-laws. The determination of the resident's capacity was not completed until 09/15/09, at which time, he was determined to possess the capacity to make his own health care decisions. There was no indication why the resident's MPOA representative had signed the document, nor was there evidence the document had been reviewed with the resident to see whether he agreed. c) Resident #46 Medical record review, on 090/2/09, revealed this resident was admitted to the facility on [DATE]. Upon admission, the person whom this resident had appointed as her MPOA representative signed for the resident to be resuscitated in the event of cardiopulmonary arrest. There was no evidence of the resident's involvement in this decision. This was verified by the social worker at 4:00 p.m. on 09/22/09. At the time the MPOA signed for resuscitation, the resident had not been determined to lack the capacity to make informed health care decisions. In fact, on 09/09/09, the physician evaluated the resident and determined she did possess the capacity for medical decision making. .",2014-12-01
10805,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,279,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, resident interviews, and staff interviews,the facility failed to develop care plans based on the resident's comprehensive assessment to promote each resident's highest practicable level of well-being. Care plans were not consistently implemented, and goals and problem statements were in conflict in some instances. Additionally, goals were not always stated in measurable terms to provide a basis for making a determination of progress toward the goal. Two (2) of fifteen (15) current residents on the sample were found to be affected. Resident identifiers: #81 and #49. Facility census: 86. Findings include: a) Resident #81 1. This resident had been admitted to the facility after having his left great toe amputated. The wound had been left open and extended up the side of his foot a short distance. A wound VAC (vacuum assisted closure) was in place. In a conversation with the director of nursing on the afternoon of 09/22/09, she commented the arteries in the resident's left leg were occluded and expressed concern about the resident's wound. Review of the resident's medical record found a report, dated 01/29/09, that noted the resident's left posterior tibial artery and left superficial femoral artery were occluded. A report from the hospital, dated 08/19/09, noted he had been admitted with intermittent fevers and advancing weakness. He had undergone repeated debridement in the wound care clinic and had had hyperbaric treatments. The report noted there had been advancing blackness at the tip of the toe and advancing [DIAGNOSES REDACTED]. The resident's care plan included the following goal: ""The Resident will experience maximum peripheral circulation without complications x __ days."" The number of days was not entered into the blank. This goal was not stated in measurable terms. On 09/22/09, the resident was out of bed much of the day. He was engaged in various activities, including going to therapy. When he was returned to bed at 3:20 p.m., it was noted he had been up in a wheelchair with nothing to elevate his feet. The interventions for the goal regarding maintaining maximum peripheral interventions were to ""administer and monitor anticoagulation therapy as ordered; to assess and monitor for coolness, mottling, pallor, etc., and to monitor for skin breakdown."" The use of the wound VAC was not mentioned. There were no nursing interventions to promote maintenance of peripheral circulation. 2. Another goal was: ""The resident's wound will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and presence of granulation x 30 days."" The interventions were: ""Monitor for effectiveness and/or side effects of medication. Monitor for verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered. Provide wound treatment as ordered. Monitor Wound Vac dressing Q (every) shift to ensure proper placement and functioning. Keep setting at 125 continuously. Change dressing Q (every) 3 days and PRN (as needed)."" For the most part, the interventions did not include proactive nursing interventions to promote wound healing. b) Resident #49 1. The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/20/09, indicated she had short-term and long-term memory problems. According to the assessment, she was unable to recall the current season, the location of her room, staff names/faces, or that she was in a nursing home. She was coded as having indicators of [MEDICAL CONDITION], in that she had new onset or worsening of being easily distracted, having periods of altered perception or awareness of her surroundings, periods of restlessness, and her mental function varied over the course of the day. She was assessed as having deteriorated in the area of cognitive status. The assessment also indicated she could usually be understood and sometimes was able to understand. Her ability to express, understand, or hear information had deteriorated in comparison to her abilities ninety (90) days before. Furthermore, her attending physician had determined her to lack the capacity to make medical decisions on 08/18/09. This was prior to the end of the assessment reference period of the MDS, on which the care plan was developed. The resident's care plan included a problem statement, written by a licensed practical nurse (LPN - Employee #22), of: ""POST (Physician order [REDACTED]. MPOA (medical power of attorney) to make the resident's healthcare decisions."" The associated goal, initiated on 09/03/09, was: ""(Resident's first name) shall participate in decisions regarding medical care and treatment x 90 days."" The problem statement noted the resident's MPOA representative would make the resident's health care decisions. The goal indicated the resident was to make her own health care decisions. The resident's assessment, in conjunction with the physician's determination of incapacity to make health care decisions, made the goal specious. 2. Another problem statement, written by Employee #22 on 08/27/09, was: ""Resident exhibits symptoms of [MEDICAL CONDITION] due to mental status changes after recent surgery, underlying infection / metabolic diagnosis, delusions, screaming / yelling out."" The associated goal was: ""(Resident's first name) will be free of signs / symptoms of [MEDICAL CONDITION] with no unexplained or rapid changes in mental status, mood, and behavior or communication ability throughout review."" The target date was 11/25/09. This goal was not measurable. Additionally, this goal was written approximately one (1) week prior to the goal for her to make her own health care decisions. Both goals were written by the same licensed practical nurse. If the resident's [MEDICAL CONDITION] had resolved, it should have been so noted. If the resident's [MEDICAL CONDITION] persisted, the goal for her to make health care decisions was inappropriate. [MEDICAL CONDITION] is considered a medical emergency, and immediate assessment of the underlying causes needs to occur. 3. Another goal was: ""Resident will demonstrate increased ability to understand others as evidenced by making her needs known throughout review period."" This goal, initiated on 09/03/09, was not measurable. 4. Another goal was: ""Resident will voice decreased episodes of depression x 30 days"" was initiated on 09/03/09. The goal was not written in measurable terms. .",2014-12-01
10806,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,164,D,0,1,7F5X11,"Based on observations, the facility failed to ensure privacy during medical treatment for one (1) of three (3) residents for whom a treatment was observed. The resident's body was exposed more than was necessary during a treatment to her coccyx. Resident identifier: #30. Facility census: 86. Findings include: a) Resident #30 On the mid-afternoon of 09/22/09, a dressing change for this resident was observed. The resident was in bed and was turned onto her right side by a nursing assistant (Employee #35), so a licensed practical nurse (LPN - Employee #103) could do the treatment to the resident's coccyx area. The resident had on a hospital-type gown that was not tied in the back. The resident was exposed posteriorly from head to toe, although only the area of the coccyx needed to be uncovered. .",2014-12-01
10807,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,314,D,0,1,7F5X11,"Based on observations of wound care, the facility failed to ensure each resident received the necessary care and treatment to promote wound healing. One (1) of three (3) treatment observations revealed the wound was packed too tightly, creating a potential for damaging tissues. Resident identifier: #30. Facility census: 86. Findings include: a) Resident #30 On 09/22/09, a licensed practical nurse (LPN - Employee #103) was observed providing wound care to a pressure ulcer on the resident's coccyx. After the wound was cleaned and dried, the nurse used a Q-tip to pack the wound with a calcium alginate dressing. The nurse used sufficient force to cause the skin around the wound to rise. The whole dressing was packed into the wound tightly, rather than loosely to avoid damaging fragile tissue. .",2014-12-01
10808,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,412,D,0,1,7F5X11,"Based on observations, medical record review, resident interview, and staff interviews, the facility failed to ensure each resident received assistance in making dental appointments to repair and adjust a resident's dentures. A resident said his dentures needed to be ""fixed"", and an appointment was to have been made, but it had been a long time and he had not heard anything. One (1) of fifteen (15) current residents was affected. Resident identifier: #52. Facility census: 86. Findings include: a) Resident #52 During an interview with the resident on 09/25/09 at approximately 10:30 a.m., the resident brought up the subject of his dentures. He said the social worker had said she would make an appointment for him to see the dentist about his dentures. He said that had been quite a while ago. He further stated his a tooth had been knocked out of his denture when staff had been cleaning them. The resident said he was not worried about that, but said he had lost a lot of weight and his dentures no longer fit. (The resident said he had lost the weight during his illness prior to being admitted to the facility.) He said he wanted his dentures fixed and did not know what had happened about his appointment. Review of the medical record found an entry by the social worker, dated 07/09/09, regarding his dental appointment. The social worker had noted the resident was interested in getting new dentures and had agreed to consult with Dr. ____. According to the notation, a call had been placed to the dentist's office, and he was to come to the center for the first consult. He would then advise them of what needed to be done. She noted she had explained Medicaid payment to the daughter. No additional information could be found regarding the dental appointment. The director of nursing and other staff were asked about this. On 09/25/09 at approximately 11:15 a.m., it was reported the dentist's office had been contacted. The dentist's receptionist had forgotten to tell the dentist of the consult. There had been no follow-up on the dental consult after 07/09/09. .",2014-12-01
10809,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,371,F,0,1,7F5X11,"Based on observation, food temperature measurements, and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 86. Findings include: a) During the initial tour of the dietary department on 09/21/09 at 7:00 p.m., the following sanitation infractions were identified: 1. During observation of dish washing, a cook removed plastic tumblers from a dishwasher rack and inverted them on a tray without allowing them to air dry. The tray did not have a product to raise the tumblers off the tray to allow for air drying. Moisture was trapped within the tumblers, creating a medium for bacterial growth. 2. Lids were placed on sippy cups prior to air drying. 3. A dietary employee wiped his face and nose, then resumed handling clean dishes without washing his hands. 4. Plate covers and lids were peeling around the edges. On 09/22/09 at 10:50 a.m., a dietary employee (Employee #69) stated she had been having to wipe the plastic from the plates. b) During observation of the preparation of the noon meal on 09/23/09, the following sanitation infractions were identified and discussed with the dietary manager (DM): 1. Hot foods were not held by a method to assure they maintained safe temperatures. Five (5) food products were observed on top of the oven, while other food items were being prepared in the oven. When the temperatures were measured by the DM, the pureed meat was 110 degrees F., regular meat was 100 degrees F., ground veal was 110 degrees F., potatoes were 125 degrees F., and pureed potatoes were 125 degrees F. 2. Tomato soup was observed on the steam table. It was 120 degrees F. Employee #69, when asked how the soup had been prepared, stated she had prepared it by allowing it to warm on the steam tables. This is not an approved rapid method of cooking foods, to assure the prevention of hazardous microorganisms. A steam table is for holding food, not cooking foods. 3. Flies were observed in the food preparation and serving areas. They were observed again at noon on 09/23/09. 4. The toaster was observed with crumbs adhered to the moving parts by a sticky substance. It also contained rusted metal parts. 5. At 11:30 a.m., bean-vegetable salads were stacked three (3) and four (4) trays deep on food chillers. The DM was asked to check the temperature of one (1) of the salads on top. It was 50 degrees F. 6. The trays on which the meals were served had not been air dried prior to stacking them. They were noted with trapped moisture. .",2014-12-01
10810,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,309,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure continuity of care for one (1) resident, who was receiving [MEDICAL TREATMENT] services, of a sample of fifteen (15) facility residents. Additionally, the facility did not consistently monitor the status of the resident's vascular access as ordered by the physician. Resident identifier: #16. Facility census: 86. Findings include: a) Resident #16 Medical record review, on 09/24/09, revealed this resident was receiving [MEDICAL TREATMENT] services from a local [MEDICAL TREATMENT] provider. There was no agreement with the [MEDICAL TREATMENT] provider to delineate the responsibilities of the provider and the responsibilities of the facility regarding the [MEDICAL TREATMENT] service for this resident. There was no evidence of coordination of services between the facility and the [MEDICAL TREATMENT] provider. For example, weights and laboratory tests were being done by the [MEDICAL TREATMENT] provider; however, this information was not being provided to the facility to assure continuity of care. Upon inquiry, it was revealed the facility was not having any communication with the [MEDICAL TREATMENT] provider and was receiving no information regarding the status of the resident. This was confirmed during an interview with the director of nursing (DON) at 1:30 p.m. on 09/24/09. Additionally, the resident had a physician's orders [REDACTED]. Review of the resident's September 2009 treatment administration record (TAR), with the DON, revealed no evidence of monitoring on 09/20/09 during for the 7-3 and 11-7 shifts; no monitoring on 09/20/09 or 09/21/09 during the 11-7 shift; no monitoring on 09-22-09 during the 7-3 and 11-7 shifts; and no monitoring on 09/23/09 during the 11-7 shift. .",2014-12-01
10811,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,364,C,0,1,7F5X11,"Based on observation, menu review, and staff interview, the facility failed to assure meals were attractive. Foods planned on the menu were all of one (1) color. In addition, no garnishes were planned for residents who required mechanically altered or pureed diets. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 86. Findings include: a) Observation during the noon meal, at 11:20 a.m. on 09/23/09, revealed the meal which was planned and served included sausages, french fries, and bean and vegetable salad. The menu called for sliced pears with gelatin sprinkles, but apples were substituted. All the foods were white to brown in color. No garnishes were used. In addition, garnishes were not planned for any meals except those of regular consistency. No garnishes were planned for mechanically altered or pureed meals. At 11:30 a.m., an interview was conducted with the dietary manager (DM), regarding the appearance of the meal. At that time, the DM confirmed the planned meal did not have variety in color. When asked about garnishes, the DM confirmed that all residents should have the benefit of an attractive meal presentation, through the use of garnishes, no matter what consistencies they might require. .",2014-12-01
10812,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,282,C,0,1,7F5X11,"Based on staff interview, the facility failed to assure nursing assistants have available information to provide individualized care and services, in accordance with each resident's care plan. This practice has the potential to affect all facility residents. Facility census: 86. Findings include: a) An interview was conducted with a nursing assistant (NA) at 9:00 a.m. on 09/22/09, regarding how the NAs know the specific care plan interventions for each resident, which they (the NAs) were to implement. The NA stated, ""The nurses tell us."" Further interview revealed the NAs had nothing in writing, such as a cardex or other type of individualized tool to which they could refer, to assure each resident was provided care and services as ordered. On 09/22/09 at 10:00 a.m., the director of nursing (DON) confirmed the facility did not have a method in place to provide the nursing assistants information regarding the individualized care for each resident. The DON stated the facility had been discussing the need to put something like this in place. During the afternoon of 09/22/09, the DON provided a description of a form the facility was considering implementing. .",2014-12-01
10813,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,369,D,0,1,7F5X11,"Based on observation and staff interview, the facility failed to assure special adaptive eating equipment was available for each resident at each meal. One (1) resident was not provided a special drinking cup at the noon meal on 09/23/09. Resident identifier: 21. Facility census: 86 Findings include: a) Resident #21 During observation of meal tray preparation at noon on 09/23/09, dietary staff stated that a Kennedy cup was not available to place on this resident's tray. Upon inquiry, a dietary employee (Employee #69) stated the resident probably kept the cup in her room after breakfast. The dietary manager then stated there were more of these cups ""across the hall"" in storage, and that one (1) of them should have been retrieved to use for the resident. .",2014-12-01
10814,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,315,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to assess a resident's potential for bladder retraining. This was evident for one (1) of fifteen (15) sampled residents. Resident identifier: #65. Facility census: 86. Findings include: a) Resident #65 Review of Resident #65's medical record revealed a minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/10/09. In Section H.1.b., the assessor coded her as being continent of urine for the preceding fourteen (14) days over all shifts. Review of the physician's orders [REDACTED]. Review of the medical record revealed a two-page ""Urinary Incontinence Assessment"" form dated 04/04/09, which contained no information under section B regarding nursing interventions and care planning and action, nor under section C regarding evaluation of the program, nor under section D regarding comments. Review of the nursing assistant's daily activity log for this resident revealed this resident had been incontinent eight (8) times throughout the month of May over the course of all shifts; this count was confirmed during an interview with a licensed practical nurse (LPN - Employee #29) at 3:30 p.m. on 09/22/09. Review of the significant change in status MDS, with an ARD of 06/08/09, found Section H.1.b. coded to indicate she was incontinent of urine with multiple daily episodes over the past fourteen (14) days, and pads / briefs were being used. Section H.3. was not marked to indicate the resident was on any scheduled toileting plan or bladder retraining program. The accompanying Care Plan Team Meeting Summary, dated 06/18/09, stated this resident ""recently exhibited a significant change in status due to her decline in continence and ADL's (activities of daily living) related to recent [MEDICAL CONDITION] while out to the hospital."" The resident assessment protocol (RAP) documentation associated with the significant change MDS, dated [DATE], noted the decision to care plan for urinary incontinence to minimize risks and avoid complications, stating: ""She is at risk for infection related (to) bowel and bladder incontinence."" Another two-page Urinary Incontinence Assessment, with a start date of 06/02/09, revealed the plan to initiate a Three-Day Continence Management Diary, noting this was discussed with the resident who was not willing to continue with the continence management program. Medical record review revealed no evidence of a Three-Day Continence Management Diary form. Review of the nursing notes revealed an indwelling Foley urinary catheter was removed on 06/02/09, and there was no mention of a voiding diary / voiding assessment for the following three (3) days, nor was there any notation that it was offered to the resident. Review of the nursing assistant's ADL flow sheets revealed a decline in urinary continence as follows: May 2009 - eight (8) episodes of urinary incontinence; June 2009 - one hundred fifty-five (155) episodes; July 2009 - one hundred seventy-none (179) episodes; August 2009 - one hundred twenty-five (125) episodes; September 2009 - one hundred thirty-nine (139) episodes through 09/24/09. During interview with the Alzheimer's unit coordinator (Employee #43) on 09/25/09 at 10:30 a.m., she said Resident #65 was a Stage 5 dementia patient and they were usually not retrainable, especially after a [MEDICAL CONDITION]. She said it was their unit's unwritten policy to toilet all their residents upon rising, before and after each meal, at bedtime, and as needed, noting they were probably toileted at least every two (2) hours or more. At this time, the director of nursing (DON - Employee #44) said the resident must have had the three (3) day voiding diary, because the Urinary Incontinence Assessment form was on the chart. The DON said the voiding diary may be in the medical records department, and the medical records person was not here today to ask, or perhaps the form was discarded, as it is only a worksheet. Review of Resident #65's care plan revealed a focus area of incontinence with interventions to provide peri care / incontinence care as needed and to apply barrier cream with each cleansing. There was no mention in the care plan of voiding assessments, toileting programs, or scheduled toileting. During interview shortly before noon on 09/25/09, the DON spoke her understanding of a concern that review of Resident #65's medical record gave the impression that staff asked the resident if she wanted to participate in a continence management program, she said no, and no voiding diary was kept to assess when the resident voided on her own and/or to analyze her own voiding pattern (noting this was different than staff toileting her on their schedule). The DON said the initial MDS probably contained a coding error, because there has been urinary incontinence for this resident from the beginning. Review of the admission nursing assessment revealed documentation to indicate the resident was incontinent ""at times"". Review of the facility's policy on ""Continence Management 5.10"" found: ""The Urinary Incontinence Assessment and/or Bowel Retraining Assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition. Continence status will be reviewed quarterly with the Minimum Data Set (MDS) and with significant change."" A voiding diary for Resident #65 was not produced prior to exit. .",2014-12-01
10815,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-08-17,157,E,1,0,YCK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of self-reported allegations of abuse / neglect, staff interview, and policy review, the facility failed to notify the physician timely when a resident did not receive medications in accordance with physician orders [REDACTED]. This affected ten (10) of ten (10) sampled residents. Resident identifiers: #4, #8, #41, #44, #57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - [MEDICATION NAME] 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - [MEDICATION NAME] 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - [MEDICATION NAME] 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - [MEDICATION NAME] 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - [MEDICATION NAME] XL 300 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 - [MEDICATION NAME] sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - [MEDICATION NAME] 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 17 grams in 8 oz water by mouth for constipation - refused 3 of 31 doses - [MEDICATION NAME] OTC 20 mg 1 tablet by mouth for [MEDICAL CONDITION] reflux - refused 3 of 31 doses - [MEDICATION NAME] liquid 400 mg by mouth twice daily as an appetite stimulant - refused 20 of 62 doses, missed 8 additional doses (reason either unspecified or unclear), and no initials were present to indicate whether 1 doses was administered or not - [MEDICATION NAME] 10 mg by mouth at bedtime for dementia with behavior disturbances - refused 11 of 31 doses and missed 5 additional doses (reason not specified) - [MEDICATION NAME] 10/100 1 tablet by mouth three-times-daily for [MEDICAL CONDITION] - refused 43 of 93 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 7.5 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 On the reverse side of the MAR for the medications ordered for administration on an ""as needed"" (PRN) basis, nurses recorded that medications offered at 9:00 p.m. on the following dates were not administered because the resident would not awaken to take them - 10/01/10 through 10/06/10, 10/11/10, 10/12/10, 10/15/10, 10/16/10, and 10/22/10. Further review of MARs, from November 2010 through January 2011, found documentation reflecting multiple doses of medications were not being administered as ordered by the physician. Coding on the MARs indicated the resident would frequently refuse to take his scheduled doses of medications; however, he had multiple additional missed doses, the reasons for which were either unspecified or not clearly stated. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered - for whatever reason. - 2. On 02/10/11, the following medications were discontinued: [MEDICATION NAME] sodium, [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME] 7.5 mg twice daily (which was started on 12/29/10), and [MEDICATION NAME]. (Previously, [MEDICATION NAME] had been discontinued on 01/07/11.) On 02/21/11, the physician ordered [MEDICATION NAME] 2 mg by mouth twice daily for tremors. Review of the MARs from February to April 2011 revealed multiple missed doses for which staff failed to record the reason for not administering them, and the [MEDICATION NAME] was discontinued on 04/14/11. - 3. On 04/14/11, the physician ordered the following medications: [REDACTED] - [MEDICATION NAME] 10/100 1 tablet by mouth three-times daily for [MEDICAL CONDITION] - [MEDICATION NAME] 200 mg by mouth for arthritis - Klonopin 0.5 mg 1 tablet by mouth three-times-daily for agitation (which was subsequently changed to 0.25 mg twice daily on 04/28/11, and back to 0.5 mg three-times-daily on 06/17/11) On 06/14/11, the physician ordered [MEDICATION NAME] SR 150 mg by mouth daily for depression. Review of the MARs for April, May, and June 2011 found virtually all scheduled doses of these medications were not administered. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered over this 2-1/2 month period. - 4. Review of Resident #78's care plan, last revised on 07/05/11, revealed the following intervention (created on 07/02/11) to address problems associated with unrelieved pain: ""Resident to be given all medications with MPOA (medical power of attorney) and second nurse present per MPOA request."" There was no evidence of any plan having been implemented prior to 07/05/11 to address the need to monitor the resident's overall health status related to various health conditions (e.g., hypertension, constipation, [MEDICAL CONDITION], etc.) that would have been affected by frequent missed doses of scheduled medications and/or by the discontinuation of medications to treat these conditions. - 5. Review of the facility's self-reported allegations of abuse / neglect found an report of an allegation of neglect made by Resident #78's spouse, dated 07/05/11, stating (quoted as written), ""Resident Responsible party reported to this social worker on this date alligations of neglect stating nursing failed to give medications per order and neglected to notify responsible party & physician when documented refusal to take medications. Investigation being conducted."" - 6. During an interview with the administrator and the director of nursing (DON) on 08/16/11 at 11:30 a.m., the DON presented policies about medication administration, but the policies did not address what actions staff was to take when a resident repeatedly refused medications - beyond the action of documenting the refusal by circling the nurse's ""initials in the date and time space where that medication is ordered, and document(ing) patient's refusal of medication on the back of the MAR"". (Policy titled ""8.4 Medication Administration: General"" revised 05/01/11.) The DON stated they implemented a new practice whereby, if a resident misses 3 doses of any medication, the physician is to be notified as well as the resident's responsible party. They verified Resident #78 did not receive his medications as ordered over an extended period of time and that neither the physician nor the resident's responsible party had been notified when this occurred. - 7. Residents #4, #8, #41, #44,57, #62, #75, #79, and #80 Further review of the facility's self-reported allegations of abuse / neglect found the facility identified, upon investigating concerns about medication administration with Resident #78, nine (9) other residents who did not receive their medications as ordered. An interview with the administrator and DON, on 08/16/11 at 11:30 a.m., found they identified a total of ten (10) residents (including Resident #78) who frequently did not to receive their medications as ordered. They said they implemented a plan to address this, which included notification of the resident's physician and notification of the resident's responsible party (in the event the resident had a surrogate decision-maker acting on his or her behalf due to a determination of incapacity). .",2014-12-01
10816,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-08-17,309,E,1,0,YCK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure each resident received medications as ordered by the physician, failed to promptly notify the physician when a resident frequently refused one (1) or more medications, failed to notify the responsible party when the resident did not received scheduled doses of medications for an extended period of time, and failed to establish a care plan to address either the resident's refusal of medications or to address the need to monitor those health conditions for which the medications were not have been administered (but were not). This affected ten (10) of (10) sampled residents. Resident identifiers: #4, #8, #41, #44, #57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - [MEDICATION NAME] 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - [MEDICATION NAME] 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - [MEDICATION NAME] 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - [MEDICATION NAME] 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - [MEDICATION NAME] XL 300 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 - [MEDICATION NAME] sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - [MEDICATION NAME] 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 17 grams in 8 oz water by mouth for constipation - refused 3 of 31 doses - [MEDICATION NAME] OTC 20 mg 1 tablet by mouth for [MEDICAL CONDITION] reflux - refused 3 of 31 doses - [MEDICATION NAME] liquid 400 mg by mouth twice daily as an appetite stimulant - refused 20 of 62 doses, missed 8 additional doses (reason either unspecified or unclear), and no initials were present to indicate whether 1 doses was administered or not - [MEDICATION NAME] 10 mg by mouth at bedtime for dementia with behavior disturbances - refused 11 of 31 doses and missed 5 additional doses (reason not specified) - [MEDICATION NAME] 10/100 1 tablet by mouth three-times-daily for [MEDICAL CONDITION] - refused 43 of 93 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 7.5 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 On the reverse side of the MAR for the medications ordered for administration on an ""as needed"" (PRN) basis, nurses recorded that medications offered at 9:00 p.m. on the following dates were not administered because the resident would not awaken to take them - 10/01/10 through 10/06/10, 10/11/10, 10/12/10, 10/15/10, 10/16/10, and 10/22/10. Further review of MARs, from November 2010 through January 2011, found documentation reflecting multiple doses of medications were not being administered as ordered by the physician. Coding on the MARs indicated the resident would frequently refuse to take his scheduled doses of medications; however, he had multiple additional missed doses, the reasons for which were either unspecified or not clearly stated. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered - for whatever reason. - 2. On 02/10/11, the following medications were discontinued: [MEDICATION NAME] sodium, [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME] 7.5 mg twice daily (which was started on 12/29/10), and [MEDICATION NAME]. (Previously, [MEDICATION NAME] had been discontinued on 01/07/11.) On 02/21/11, the physician ordered [MEDICATION NAME] 2 mg by mouth twice daily for tremors. Review of the MARs from February to April 2011 revealed multiple missed doses for which staff failed to record the reason for not administering them, and the [MEDICATION NAME] was discontinued on 04/14/11. - 3. On 04/14/11, the physician ordered the following medications: [REDACTED] - [MEDICATION NAME] 10/100 1 tablet by mouth three-times daily for [MEDICAL CONDITION] - [MEDICATION NAME] 200 mg by mouth for arthritis - Klonopin 0.5 mg 1 tablet by mouth three-times-daily for agitation (which was subsequently changed to 0.25 mg twice daily on 04/28/11, and back to 0.5 mg three-times-daily on 06/17/11) On 06/14/11, the physician ordered [MEDICATION NAME] SR 150 mg by mouth daily for depression. Review of the MARs for April, May, and June 2011 found virtually all scheduled doses of these medications were not administered. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered over this 2-1/2 month period. - 4. Review of Resident #78's care plan, last revised on 07/05/11, revealed the following intervention (created on 07/02/11) to address problems associated with unrelieved pain: ""Resident to be given all medications with MPOA (medical power of attorney) and second nurse present per MPOA request."" There was no evidence of any plan having been implemented prior to 07/05/11 to address the need to monitor the resident's overall health status related to various health conditions (e.g., hypertension, constipation, [MEDICAL CONDITION], etc.) that would have been affected by frequent missed doses of scheduled medications and/or by the discontinuation of medications to treat these conditions. - 5. Review of the facility's self-reported allegations of abuse / neglect found an report of an allegation of neglect made by Resident #78's spouse, dated 07/05/11, stating (quoted as written), ""Resident Responsible party reported to this social worker on this date alligations of neglect stating nursing failed to give medications per order and neglected to notify responsible party & physician when documented refusal to take medications. Investigation being conducted."" - 6. During an interview with the administrator and the director of nursing (DON) on 08/16/11 at 11:30 a.m., the DON presented policies about medication administration, but the policies did not address what actions staff was to take when a resident repeatedly refused medications - beyond the action of documenting the refusal by circling the nurse's ""initials in the date and time space where that medication is ordered, and document(ing) patient's refusal of medication on the back of the MAR"". (Policy titled ""8.4 Medication Administration: General"" revised 05/01/11.) The DON stated they implemented a new practice whereby, if a resident misses 3 doses of any medication, the physician is to be notified as well as the resident's responsible party. They verified Resident #78 did not receive his medications as ordered over an extended period of time and that neither the physician nor the resident's responsible party had been notified when this occurred. - 7. Residents #4, #8, #41, #44,57, #62, #75, #79, and #80 Further review of the facility's self-reported allegations of abuse / neglect found the facility identified, upon investigating concerns about medication administration with Resident #78, nine (9) other residents who did not receive their medications as ordered. An interview with the administrator and DON, on 08/16/11 at 11:30 a.m., found they identified a total of ten (10) residents (including Resident #78) who frequently did not to receive their medications as ordered. They said they implemented a plan to address this, which included notification of the resident's physician and notification of the resident's responsible party (in the event the resident had a surrogate decision-maker acting on his or her behalf due to a determination of incapacity). .",2014-12-01
10817,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-08-17,428,E,1,0,YCK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, policy review, and contract review, the facility failed ensure the consultant pharmacist identified and reported irregularities in the medication regimens of ten (10) of ten (10) sampled residents to the attending physician and the director of nursing. Resident identifiers: #4, #8, #41, #44,57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - Seroquel 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - Valium 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - Namenda 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - Cardura 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - Wellbutrin XL 300 mg 1 tablet by mouth for depressive disorder - refused 1 of 14 doses; med discontinued on 10/14/10 - Docusate sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - Aggrenox 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional doses (reason either unspecified or unclear) - Miralax 17 grams in 8 oz water by mouth for constipation - refused 3 of 31 doses - Prilosec OTC 20 mg 1 tablet by mouth for esophageal reflux - refused 3 of 31 doses - Megace liquid 400 mg by mouth twice daily as an appetite stimulant - refused 20 of 62 doses, missed 8 additional doses (reason either unspecified or unclear), and no initials were present to indicate whether 1 doses was administered or not - Aricept 10 mg by mouth at bedtime for dementia with behavior disturbances - refused 11 of 31 doses and missed 5 additional doses (reason not specified) - Sinemet 10/100 1 tablet by mouth three-times-daily for Parkinson's disease - refused 43 of 93 doses and missed 5 additional doses (reason either unspecified or unclear) - Mobic 7.5 mg 1 tablet by mouth for osteoarthritis - refused 1 of 14 doses; med discontinued on 10/14/10 On the reverse side of the MAR for the medications ordered for administration on an ""as needed"" (PRN) basis, nurses recorded that medications offered at 9:00 p.m. on the following dates were not administered because the resident would not awaken to take them - 10/01/10 through 10/06/10, 10/11/10, 10/12/10, 10/15/10, 10/16/10, and 10/22/10. Further review of MARs, from November 2010 through January 2011, found documentation reflecting multiple doses of medications were not being administered as ordered by the physician. Coding on the MARs indicated the resident would frequently refuse to take his scheduled doses of medications; however, he had multiple additional missed doses, the reasons for which were either unspecified or not clearly stated. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered - for whatever reason. - 2. On 02/10/11, the following medications were discontinued: Docusate sodium, Aricept, Cardura, Miralax, Prilosec, Wellbutrin, Sinemet, Namenda, Aggrenox, Mobic 7.5 mg twice daily (which was started on 12/29/10), and Valium. (Previously, Megace had been discontinued on 01/07/11.) On 02/21/11, the physician ordered Valium 2 mg by mouth twice daily for tremors. Review of the MARs from February to April 2011 revealed multiple missed doses for which staff failed to record the reason for not administering them, and the Valium was discontinued on 04/14/11. - 3. On 04/14/11, the physician ordered the following medications: [REDACTED] - Sinemet 10/100 1 tablet by mouth three-times daily for Parkinson's disease - Celebrex 200 mg by mouth for arthritis - Klonopin 0.5 mg 1 tablet by mouth three-times-daily for agitation (which was subsequently changed to 0.25 mg twice daily on 04/28/11, and back to 0.5 mg three-times-daily on 06/17/11) On 06/14/11, the physician ordered Wellbutrin SR 150 mg by mouth daily for depression. Review of the MARs for April, May, and June 2011 found virtually all scheduled doses of these medications were not administered. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered over this 2-1/2 month period. - 4. Review of Resident #78's care plan, last revised on 07/05/11, revealed the following intervention (created on 07/02/11) to address problems associated with unrelieved pain: ""Resident to be given all medications with MPOA (medical power of attorney) and second nurse present per MPOA request."" There was no evidence of any plan having been implemented prior to 07/05/11 to address the need to monitor the resident's overall health status related to various health conditions (e.g., hypertension, constipation, Parkinson's disease, etc.) that would have been affected by frequent missed doses of scheduled medications and/or by the discontinuation of medications to treat these conditions. - 5. Review of the facility's self-reported allegations of abuse / neglect found an report of an allegation of neglect made by Resident #78's spouse, dated 07/05/11, stating (quoted as written), ""Resident Responsible party reported to this social worker on this date alligations of neglect stating nursing failed to give medications per order and neglected to notify responsible party & physician when documented refusal to take medications. Investigation being conducted."" - 6. During an interview with the administrator and the director of nursing (DON) on 08/16/11 at 11:30 a.m., the DON presented policies about medication administration, but the policies did not address what actions staff was to take when a resident repeatedly refused medications - beyond the action of documenting the refusal by circling the nurse's ""initials in the date and time space where that medication is ordered, and document(ing) patient's refusal of medication on the back of the MAR"". (Policy titled ""8.4 Medication Administration: General"" revised 05/01/11.) The DON stated they implemented a new practice whereby, if a resident misses 3 doses of any medication, the physician is to be notified as well as the resident's responsible party. They verified Resident #78 did not receive his medications as ordered over an extended period of time and that neither the physician nor the resident's responsible party had been notified when this occurred. - 7. Residents #4, #8, #41, #44,57, #62, #75, #79, and #80 Further review of the facility's self-reported allegations of abuse / neglect found the facility identified, upon investigating concerns about medication administration with Resident #78, nine (9) other residents who did not receive their medications as ordered. An interview with the administrator and DON, on 08/16/11 at 11:30 a.m., found they identified a total of ten (10) residents (including Resident #78) who frequently did not to receive their medications as ordered. They said they implemented a plan to address this, which included notification of the resident's physician and notification of the resident's responsible party (in the event the resident had a surrogate decision-maker acting on his or her behalf due to a determination of incapacity). - 8. Review of the consultant's medication regimen reviews for the above ten (10) residents found the pharmacist failed to identify any of the missed doses for these residents as drug irregularities. The administrator noted the pharmacist did not routinely check for missed medications and that the facility preferred to keep this in-house, rather than depend on the pharmacist for this. - 9. Review of the pharmacy contract with the administrator, on 08/17/11 at 9:00 a.m., found this facility was not included on the list of facilities with which there was an agreement to received professional services from the pharmacy. Other sister facilities in the same corporation were included in the agreement, but this facility was not. (As of exit on 08/17/11, no additional information was found, and the administrator confirmed that the contract did not include services provided to this facility.) Review of a contract between the pharmacy and sister facilities within the same corporation found the following Pharmacy Consulting Services Requirements: ""(Name of pharmacy) will provide pharmacy consulting services in conjunction with facility's duties under applicable law. Such duties may include, as applicable, monthly inspections to each of the Facility's nursing stations, the drug storage area and medical records to monitor compliance with pharmacy, to monitor compliance with pharmacy policies and procedures and state and federal regulations; The provision or a written report regarding the inspections and the results of the DRR (Drug Regimen Review) noting any irregularities of concern. ..."" .",2014-12-01
10818,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-08-17,500,F,1,0,YCK011,". Based on a review of facility contracts and staff interview, the facility failed to have a written agreement govern the professional services provided by the consultant pharmacist who conducted medication regimen reviews for residents at the facility. This had the potential to affect all residents in the facility. Facility census: 77. Findings include: a) Review of the pharmacy contract with the administrator, on 08/17/11 at 9:00 a.m., found this facility was not included on the list of facilities with which there was an agreement to received professional services from the pharmacy. Other sister facilities in the same corporation were included in the agreement, but this facility was not. As of exit on 08/17/11, no additional information was found, and the administrator confirmed that the contract did not include services provided to this facility.",2014-12-01
10819,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2011-08-16,225,E,1,0,97WR11,". Based on record review and staff interview, the facility did not report to the appropriate State agency five (5) of thirty-five (35) ""Resident Grievance / Complaint Forms"" containing allegations of abuse / neglect involving certified nursing assistants (CNAs). Resident identifiers: #23, #68, #56, #98, and #86. Facility census: 95. Findings include: a) A review of thirty-five (35) ""Resident Grievance / Complaint Forms"" found five (5) contained allegations of abuse and/or neglect identifying CNAs as the alleged perpetrators; the CNAs involved in these five (5) events were not reported by the facility to the State Nurse Aide Registry as required. An interview with the administrator, on 08/15/11 at 4:00 p.m., revealed the facility investigated the allegations and made the determination that they did not need to be submitted to the Registry. The allegations were as follows (quoted as written): 1. Resident #23 According to a grievance form dated 06/03/11: ""Resident was standing by the ice chest near the skilled unit nurses station. She was holding the lid open when a CNA came up and placed her hand on the residents shoulder and pushed her out of the way. Resident was told by the CNA 'You know your not supposed to be back there.'"" The CNA involved was Employee #60. 2. Resident #68 According to a grievance form dated 07/26/11: ""Resident reports that a CNA on the 3p - 11p shift is sometimes mean to her and makes her feel bad."" This resident reported this same CNA has made her fell angry / hurt her feelings on (3) occasions, according to the facility's internal investigation. The CNA involved was Employee #60. 3. Resident #56 According to a grievance form dated 06/20/11: ""Resident not receiving needed care / assistance in a timely manner. ... Witnesses state that resident had utilized his call bell for incontinent care and assigned CNA was made aware of resident need."" The CNA involved was Employee #22. 4. Resident #98 According to a grievance form dated 06/20/11: ""Resident family requested resident to have shower due to not getting one since last LOA (leave of absence). Employee (name) stated no, not her scheduled day. Family member states her hair was greasy and needed to be washed. Employee began to give family member a negative attitude. ..."" The CNA involved was Employee #137. 5. Resident #86 According to a grievance form dated 08/01/11: ""(1) Resident not turned & positioned according to positioning tool. (2) Resident did not receive tray at meal time. Received 1 hr (hour) after. (3) CNA did not come into residents room or acknowledge family members."" The CNA involved was Employee #83.",2014-12-01
10820,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,309,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed, for one (1) of five (5) residents, to assess / monitor the resident after starting new medication which was known to produce the adverse side effect of decreased level of consciousness. The resident later needed emergency medical treatment after experiencing symptoms of lethargy and a decrease level of consciousness. Resident identifier: #128. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid."" - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): ""Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of residents request. Order received to send to ER for evaluation. Notified residents son per her request of ambulance transport to ER. After calling 911 for transport to hospital, notified by residents son that resident 'wont wake up.' Assessed resident again. Unresponsive. BP 90/68, HR 58 Resp 14. Remained with resident until (ambulance service) arrived."" An earlier nursing note, dated 06/29/11 at 13:35 (1:35 p.m.), stated (quoted directly as stated in the electronic medical record): ""Skilled nursing: therapy/teaching/training: Management/Evaluation; Nrsg Obsrvtn: Skilled for PT (physical therapy) and OT (occupational therapy) related to reconditioning, therapy, [MEDICAL CONDITIONS]. Observations: At beginning of shift resident complained of dizziness, which is not unusual for her. It was noted that she was not using her oxygen, her nasal cannular was lying beside her on the bed. She indicated that she had removed it. He oxygen sat. was 90% and immediately went to 92% when oxygen was given. Resident was cautioned to continue to use her oxygen. She stated that she felt better after oxygen was re administered. BP 123/72 Temperature 96.7 orally Pulse 90 and Respirations 20. NO respiratory distress noted. Resident denies pain. CBC and BMP lab result returned today and reviewed with facility doctor. No new orders at this time. Will continue to monitor resident."" - According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), [MEDICATION NAME] is a skeletal muscle relaxant which produces the following adverse reactions in greater than 10% of its users: ""Central nervous system: Drowsiness, [MEDICAL CONDITION], psychiatric disturbances, [MEDICAL CONDITION], slurred speech, ataxia (lack of muscle coordination during voluntary movements), [DIAGNOSES REDACTED] (low muscle tone which can affect muscle strength). Neuromuscular & skeletal: Weakness."" In 1% to 10% of the users, it produces the following adverse reactions: ""Cardiovascular: [MEDICAL CONDITION]. Central nervous system: Fatigue, confusion, headache. Dermatologic: Rash. Gastrologic: Nausea, constipation. [MEDICAL CONDITION]: Polyuria (excessive urination)."" The following nursing actions are recommended when administering [MEDICATION NAME]: ""Physical Assessment: Assess effectiveness and interactions of other medications patient may be taking. Monitor effectiveness of therapy (according to rational (sic) for therapy) and adverse reactions (e.g., cardiovascular and CNS (central nervous system) status at beginning of therapy and periodically with long-term use. ..."" Under the heading ""Geriatric Considerations"" was found: ""The elderly are more sensitive to the effects of [MEDICATION NAME] and are more likely to experience adverse CNS side effects at higher doses. Two cases of [MEDICAL CONDITION] were reported after inadvertent high doses (50 mg/day and 90 mg/day) were given to elderly patients."" - A review of the Medication Administration Record [REDACTED]. Review of the nursing notes found no evidence of any monitoring of the resident's reaction to the new medication after she began receiving the [MEDICATION NAME] 5 mg tid on 06/25/11. This lack of monitoring continued, and the facility increased the [MEDICATION NAME] to 20 mg tid on 06/28/11. After receiving two (2) doses of the [MEDICATION NAME] 20 mg (one (1) on 06/28/11 at 9:00 p.m. and the other on 06/29/11 at 9:00 a.m.), the resident began experiencing signs of confusion and told the staff she did not know where she was and felt she had blacked out. Before transport to a local hospital, the resident became non-responsive. - Employee #93 (the interim director of nursing) and Employee #95 (a registered nurse) both reviewed the resident's medical record on the afternoon of 08/16/11 and did not locate any documentation to show the facility had monitored the resident's physical and mental functioning after the start of this new medication. .",2014-12-01
10821,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,312,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary care and services to maintain good grooming and personal hygiene. Two (2) of eleven (11) sampled residents who were dependent on staff for grooming had unmet grooming needs. One (1) resident had long chin hairs that she wanted to have shaved, and the other had long, dirty fingernails that she wanted to have cleaned. Resident identifiers: #57 and #123. Facility census: 126. Findings include: a) Resident #123 During an interview with Resident #123 on 08/16/11 at approximately 11:30 a.m., observation found she had long hair on her chin. She said she normally has the staff shave this hair off. She said the person that normally does this did not work on Saturday or Sunday and she forgot to ask them to do shave her on Friday. This resident was cooperative with care, and there was no indication she had refused to have this facial hair removed. The resident has a [DIAGNOSES REDACTED]. As of 08/16/11 at 5:00 p.m., no one had shaved the resident. The resident's care plan stated she was dependent on staff for activities of daily living (ADLs) related to a recent fracture and history of dementia. The care plan stated she can wash her face, hands, and upper body; however, she was dependent on staff for grooming. -- b) Resident #57 During a tour of the facility on 08/15/11 at approximately 2:00 p.m., observation found Resident #57 had long dirty fingernails. When asked, she said she would like her nails cleaned, but she could not do this on her own. Employee #172 (a licensed practical nurse) said she would assist the resident with cleaning her nails. .",2014-12-01
10822,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,329,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed to ensure the medication regimen of one (1) of five (5) sampled residents was free from unnecessary drugs without adequate monitoring and without adequate indication for its use. Resident #128 received the antispastic medication [MEDICATION NAME] for approximately five (5) days before she was transferred to a local emergency department due to lethargy and decreased level of consciousness. The medical record revealed no documentation as to why the resident needed the medication, and there was no evidence to reflect nursing staff was routinely monitoring the resident for common adverse side effects affecting the central nervous system. Resident identifier: #127. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid."" - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): ""Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of residents request. Order received to send to ER for evaluation. Notified residents son per her request of ambulance transport to ER. After calling 911 for transport to hospital, notified by residents son that resident 'wont wake up.' Assessed resident again. Unresponsive. BP 90/68, HR 58 Resp 14. Remained with resident until (ambulance service) arrived."" An earlier nursing note, dated 06/29/11 at 13:35 (1:35 p.m.), stated (quoted directly as stated in the electronic medical record): ""Skilled nursing: therapy/teaching/training: Management/Evaluation; Nrsg Obsrvtn: Skilled for PT (physical therapy) and OT (occupational therapy) related to reconditioning, therapy, [MEDICAL CONDITIONS]. Observations: At beginning of shift resident complained of dizziness, which is not unusual for her. It was noted that she was not using her oxygen, her nasal cannular was lying beside her on the bed. She indicated that she had removed it. He oxygen sat. was 90% and immediately went to 92% when oxygen was given. Resident was cautioned to continue to use her oxygen. She stated that she felt better after oxygen was re administered. BP 123/72 Temperature 96.7 orally Pulse 90 and Respirations 20. NO respiratory distress noted. Resident denies pain. CBC and BMP lab result returned today and reviewed with facility doctor. No new orders at this time. Will continue to monitor resident."" - On 06/29/11 (the date of discharge to the hospital), the nurse practitioner (Employee #173) typed a discharge note which stated: ""Course in facility (narrative) ""95 y/o (year old) while, widowed female admitted to Valley Center on 06/01/2011 for rehabilitation due to deconditioning s/p marked [MEDICAL CONDITION] due to GI (gastrointestinal) bleed requiring transfusion. PMH (past medical history): dizziness/body weakness with + occult blood, [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITIONS],[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), [DIAGNOSES REDACTED], joint disease. No h (history) of tobacco abuse, no ETOH (alcohol) abuse. Family hx (history) is non-contributory. Res transferred to Hospital Emergency Dept d/t severe lethargy. ""Exam ""vs (vital signs) stable resident difficult to arouse. Pupils PEARL (pupils equal and reactive to light). Heart regular grade II/VI systolic murmur. Lungs CTAB (clear to auscultation bilaterally). ""Medications on discharge ""[MEDICATION NAME] 20 mg po tid d/t bladder spasms .... "" Nowhere else in the medical record, prior to the resident's discharge to the hospital, was there any mention of the resident experiencing bladder spasms. - According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), [MEDICATION NAME] is a skeletal muscle relaxant which produces the following adverse reactions in greater than 10% of its users: ""Central nervous system: Drowsiness, [MEDICAL CONDITION], psychiatric disturbances, [MEDICAL CONDITION], slurred speech, ataxia (lack of muscle coordination during voluntary movements), [DIAGNOSES REDACTED] (low muscle tone which can affect muscle strength). Neuromuscular & skeletal: Weakness."" In 1% to 10% of the users, it produces the following adverse reactions: ""Cardiovascular: [MEDICAL CONDITION]. Central nervous system: Fatigue, confusion, headache. Dermatologic: Rash. Gastrologic: Nausea, constipation. [MEDICAL CONDITION]: Polyuria (excessive urination)."" The following nursing actions are recommended when administering [MEDICATION NAME]: ""Physical Assessment: Assess effectiveness and interactions of other medications patient may be taking. Monitor effectiveness of therapy (according to rational (sic) for therapy) and adverse reactions (e.g., cardiovascular and CNS (central nervous system) status at beginning of therapy and periodically with long-term use. ..."" Under the heading ""Geriatric Considerations"" was found: ""The elderly are more sensitive to the effects of [MEDICATION NAME] and are more likely to experience adverse CNS side effects at higher doses. Two cases of [MEDICAL CONDITION] were reported after inadvertent high doses (50 mg/day and 90 mg/day) were given to elderly patients."" - A review of the Medication Administration Record [REDACTED]. Review of the nursing notes found no evidence of any monitoring of the resident's reaction to the new medication after she began receiving the [MEDICATION NAME] 5 mg tid on 06/25/11. This lack of monitoring continued, and the facility increased the [MEDICATION NAME] to 20 mg tid on 06/28/11. After receiving two (2) doses of the [MEDICATION NAME] 20 mg (one (1) on 06/28/11 at 9:00 p.m. and the other on 06/29/11 at 9:00 a.m.), the resident began experiencing signs of confusion and told the staff she did not know where she was and felt she had blacked out. Before transport to a local hospital, the resident became non-responsive. - Employee #93 (the interim director of nursing) and Employee #95 (a registered nurse) both reviewed the resident's medical record on the afternoon of 08/16/11 and did not locate any documentation to show the facility had monitored the resident's physical and mental functioning after the start of this new medication. Employee #93 also did not locate any documentation reflecting Resident #128 had experienced signs and symptoms of bladder spasms prior to receiving the [MEDICATION NAME]. The only reference to [MEDICATION NAME] being used to treat bladder spasms came in the discharge note prepared on 06/29/11, five (5) days after Resident #128 began receiving the medication. - The medical record revealed there were no pharmacy reviews scheduled during the time the resident received this medication. The medical record also revealed no documentation from any clinical staff, physician, or nurse practitioner prior to the resident's transfer to the hospital regarding the need for this medication.",2014-12-01
10823,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,241,E,1,0,VYDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to assure direct care staff displayed identification badges while providing care, which would enable residents to identify them. Being able to identify staff members promotes resident feelings of being involved in their care and allows for identification of an alleged perpetrator, should there be an allegation of abuse, neglect, or mistreatment of [REDACTED]. Random observations, beginning at 2:30 a.m. on 08/25/11, found four (4) of nine (9) staff members on duty did not display identification badges. Two (2) of these four (4) individuals who were not wearing identification badges worked for a temporary staffing agency and were not regular employees of the facility. This deficient practice had the potential to affect more than an isolated number of residents. Employee identifiers: #40, #43, #85, and #81. Facility census: 69. Findings include: a) Employees #40, #43, #85, and #81 1. Random observations of the resident environment, on 08/25/11 at 2:30 a.m., noted four (4) of the nine (9) direct care staff members on duty were not wearing identification badges. Interviews with these four (4) individuals elicited that two (2) of them were nursing assistants (Employees #40 and #43) and two (2) of them were nurses who worked for a temporary staffing agency (Employees #81 and #85). After inquiry concerning their lack of identification badges, all staff members subsequently produced badges from their cars, pockets, and purses. - 2. The facility policy titled ""2.22 Identification Badges"" was reviewed at 12:15 p.m. on 08/26/11. The section titled ""Policy"" stated: ""All Genesis employees are required to wear an identification badge while on duty."" The section titled ""Purpose"" stated: ""To promote safety and well being of patients, residents, employees, and visitors."" The section titled ""Process"" stated: ""1. Identification badges are to be worn while on duty using a breakaway lanyard or clip on pins with name clearly visible to others."" - 3. An interview with the administrator, at 12:15 p.m. on 08/26/11, confirmed that all employees should wear identification badges when working. .",2014-12-01
10824,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,309,D,1,0,VYDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure one (1) of six (6) residents received appropriate care and services when experiencing respiratory distress. Resident #65 was observed, at 3:00 a.m. on 08/25/11, to have signs of respiratory distress and reported having trouble breathing. An oxygen concentrator was available at bedside in her room, but no supplemental oxygen was being delivered. The nurse on duty - a licensed practical nurse (LPN) whose services were obtained by the facility through a temporary staffing agency - was not aware of a standing order to apply oxygen for shortness of breath. When this order was identified by the surveyor and conveyed to the LPN, she applied supplemental oxygen to the resident, after which the resident reported some relief. Resident identifier: #65. Facility census: 69. Findings include: a) Resident #65 During random observations conducted at 3:00 a.m. on 08/25/11, Resident #65 was noted to by lying in bed on her back. The resident appeared to be struggling for breath, as evidenced by the use of accessory muscles and the presence of audible expiratory wheezes. It was noted that an oxygen concentrator was present at the bedside, but no oxygen had been applied to the resident. The resident stated she was having trouble breathing. When asked why she wasn't wearing oxygen, she stated the nurse told her the ambulance would give her oxygen. Employee #81 (an agency LPN), when interviewed related to the resident not being provided oxygen to assist her breathing, stated she was sending Resident #65 out to the hospital. When asked why no oxygen was applied to the resident, Employee #81 stated she had called the physician to report the resident experiencing shortness of breath. She stated the physician asked what the resident's 02 sat (oxygen saturation) was, and she relayed that it was 95% on room air. She stated the physician did not order oxygen, and the resident did not have an order for [REDACTED]. Immediate review of the resident's medical record found a document entitled ""Protocol for PRN (as needed) Medications"" at the back of her physician's orders [REDACTED]."" The order also required nursing staff to assess and document the resident's vital signs and respiratory sounds. This order was pointed out to another LPN (Employee #41). This was relayed to Employee #81, who applied oxygen via nasal cannula at 2 L/min at 3:16 a.m.. A reassessment of the resident's oxygen saturation found that it had returned to 95% after five (5) minutes. The resident stated the oxygen helped. The ambulance arrived at 3:20 a.m. to transport the resident to the hospital. .",2014-12-01
10825,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,323,E,1,0,VYDK11,". Based on observation, medical record review, staff interview, and review of facility documents, the facility failed to assure physician's orders were followed to prevent injuries from falls from the bed for four (4) of six (6) sampled residents. Staff failed to assure physician-ordered safety mats were at bedside and the beds were maintained in the lowest position when occupied by these residents. Resident identifiers: #65, #67, #22, and #2. Facility census: 69. Findings include: a) Resident #65 Random observation of Resident #67's room, at 3:00 a.m. on 08/25/11, noted two (2) safety mats were folded and placed beside the wardrobe in the resident's room. No mats on the floor on either side of the resident's bed to cushion her should she roll or fall from the bed. The resident was noted to be experiencing respiratory distress at 3:00 a.m. on 08/25/11. The ambulance arrived at 3:20 a.m. on 08/25/11 to transport the resident to an acute care facility. During transfer by the emergency medical technicians (EMTs), the resident stated, ""Now you watch out for my leg. I hurt it when I fell out of bed."" The resident was noted to be gesturing toward her left leg. Review of the medical record found a current order for a low bed with safety mats to be utilized bilaterally. An interview with a nursing assistant (Employee #43), at 3:40 a.m., revealed the safety mats had not been placed by the resident's bed due to the aide forgetting to put them there. Employee #43 stated she assisted the resident to bed between 9:00 p.m. and 9:30 p.m. and just forgot to put the mats down. Review of facility documents related to falls found that Resident #65 sustained falls from her bed on 07/10/11 (with a bruise and hematoma to her left knee area) and a fall on 07/16/11 with no apparent injuries. -- b) Resident #67 Random observations, conducted on 08/25/11 at 3:50 a.m., noted a nursing assistant (Employee #78) exiting Resident #67's room carrying linen in a clear trash bag. Resident #67's bed had been left in a high position with safety mats on either side of the resident's bed. When the aide returned, she was asked what position the bed should be in when safety mats were present on the floor. Employee #78 stated that the bed should be all the way to the floor. The resident's bed was then lowered into the proper low position. Review of the medical record found a 07/28/11 physician's order for the resident to have a low bed with mats. -- c) Resident #22 Random observation of the resident sleeping environment, on 08/25/11 at 3:50 a.m., noted Resident #22's bed was in a high position with safety mats placed on each side of her bed. The registered nurse on duty (RN - Employee #85) agreed the bed should be in a low position, and she then lowered the bed. Review of the medical record found a 07/26/11 order for the resident to have a low bed and mats for fall precautions. -- d) Resident #2 Random observations, at 3:30 a.m. on 08/15/11, noted Resident #2 had a safety mat on the floor of the left side of her bed. A bedside table was positioned on the right side of her bed with no safety mat. The bedside table was placed such that the resident would strike the base of the bedside table should she roll or fall from the right side of the bed. An interview with a nursing assistant (Employee #40), following the observation, confirmed that a safety mat should be on the floor on the right side of the resident's bed. Employee #40 repositioned the bedside table and placed the mat on the floor. Review of the medical record found the resident had a physician's order for a low bed with bilateral fall mats due to high fall risk as of 11/22/09.",2014-12-01
10826,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2009-07-29,225,E,0,1,5UXH11,"Based on personnel file review and staff interview, the facility failed to screen, through a statewide criminal background check, three (3) of four (4) contracted agency employees for past criminal prosecutions prior to allowing them to have resident contact. Contract Employee identifiers: #84, #85, and #86. Facility census: 55. Findings include: a) Contract Employees #84, #85, and #86 On the afternoon of 07/28/09, a review of sampled personnel records of persons working at the facility within the past three (3) months revealed four (4) contracted employees who services were engaged through three (3) different temporary staffing agencies. Review of the personnel files of these four (4) contract employees revealed three (3) of the four (4) personnel files did not contain evidence to reflect the completion of a statewide criminal background check through the West Virginia State Police. On 07/28/09 at 3:00 p.m., the facility's director of nursing was informed that evidence of statewide background checks was not found in the personnel files of Contract Employees #84, #85, and #86. On 07/29/09 at 3:00 p.m., the facility's administrator had no additional information to provide to indicate that statewide criminal background checks were completed on these contract employees.",2014-12-01
10827,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2009-07-29,371,F,0,1,5UXH11,"Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 55. Findings include: a) On 07/29/09 at 2:00 p.m., observation found two (2) fans in the back of the walk-in refrigerator unit. Both fans had dirt and lint caked on the outside metal grate. Both fans were blowing air around inside the refrigerator which contained both cooked and raw foods. At this time, the dietary manager, who was touring with the surveyor, also observed the fans and agreed they were dirty. .",2014-12-01
10828,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-08-16,203,D,1,0,XG6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide an adequate discharge notice for one (1) of six (6) residents who had been discharged or transferred from the facility. Resident #67 was sent out to the hospital for an acute medical problem and discharged from the facility. A family interview revealed the facility did not notify the family that the resident was being discharged and would not be returning to the facility. There was nothing in the transfer / discharge notice given to the family at the time of the resident's transfer to the hospital that would indicate to the resident's family that the facility was discharging the resident with the intention of not allowing him to return. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Closed record review found Resident #67 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident was sent out to the hospital on [DATE] for an acute medical problem. Review of a copy of the transfer / discharge notice form that had been provided to the resident's family at the time of his transfer found form indicated the resident was being transferred to the hospital. The resident subsequently returned to the facility on [DATE]. Review of multidisciplinary notes found that, following the resident's return from the hospital on [DATE], the resident began exhibiting combative / abusive behaviors toward staff and other residents. Further review of multidisciplinary notes found the resident's medical condition continued to deteriorate and the facility encouraged the resident's medical power of attorney representative (MPOA) to agree to transferring the resident to the hospital for evaluation of acute medical problems, including [MEDICAL CONDITION], increased BUN (blood urea nitrogen), increased confusion, and low hemoglobin and hematocrit. The resident was transported to the hospital on [DATE], and the transfer / discharge notice form did not indicate whether the resident was being transferred or discharged . During an interview on 08/15/11, at 9:00 p.m., Resident #67's MPOA reported he had not been notified the resident had been permanently discharged (as opposed to being temporarily transferred) as soon as he left the facility. The MPOA stated the family was not aware that Resident #67 would not be permitted to return to the facility until the hospital notified the facility that the resident was ready to be discharged back to the facility. The MPOA further stated the hospital was told by the facility that the resident had behaviors and they could not provide care for him, and the family and hospital were forced to find an alternative placement for the resident. The MPOA also stated the facility did not inform him of its bed hold policy. Review of multidisciplinary notes found no documentation, recorded in his medical record prior to his discharge to the hospital, to reflect the facility had informed the resident's MPOA of the possibility the facility may refuse to take the resident back unless his behaviors were controlled. An interview with the facility's social worker (Employee #20), on 08/15/11 at 3:15 p.m., confirmed the resident's MPOA had not been notified the resident had been discharged from the facility. .",2014-12-01
10829,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-08-16,222,D,1,0,XG6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents was free of chemical restraints. Staff administered to Resident #67 an antipsychotic medication ([MEDICATION NAME]) via intramuscular injection (IM) for agitation without evidence of having first ruled out causal factors (e.g., pain, other sources of discomfort, environmental factors, etc.). [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for being uncooperative with staff and cursing. [MEDICATION NAME] 5 mg IM was given again on 03/26/11 at 11:42 p.m. for yelling ""Help"", cursing, and being physically abusive toward staff. The resident had physician's orders [REDACTED]. The [MEDICATION NAME] IM was used to control the resident's behavior, which required a lesser amount of effort by the staff and was not in the resident's best interest. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review disclosed this [AGE] year old male resident, who was initially admitted to this facility on 02/21/11, had medical diagnoses that included multiple [MEDICAL CONDITION] with [MEDICAL CONDITIONS], diabetes, hypertension, [MEDICAL CONDITION] of the prostate with metastasis, dementia, gangrenous changes in his extremities, Stage 2 pressure ulcer on the coccyx, and recent bouts with pneumonia. Review of the multidisciplinary notes disclosed the resident had been sent out to the hospital for acute medical problems and returned to the facility on [DATE]. The notes revealed that, shortly after returning to the facility, the resident began exhibiting behaviors of verbal and physical abuse toward staff and other residents at times. The notes also disclosed the resident was confused, non-ambulatory, and required assistance for most activities of daily living. Review of physician's orders [REDACTED]. In addition, [MEDICATION NAME] 0.5 mg PO (by mouth)/IM BID (twice daily) had been given on 03/16/11. Further review of multidisciplinary notes found [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for the resident being uncooperative with staff and cursing. The multidisciplinary note stated (quoted as written): ""Resident has been uncooperative cursing and call staff names and slapping at staff, tried to talk and redirect him to no avail. Gave syrexia 1ml. injection, into lt. gluteus.at 12:05AM.at 1:05AM resident calm asleep.will continue to check and monitor."" [MEDICATION NAME] IM was given again on 03/26/11 at 11:42 p.m. for yelling ""Help"", cursing, and being physically abusive toward staff. The multidisciplinary note stated (quoted as written): ""Resident yelling at top of his voice 'HELP' went to room he started calling this nurse names and cusing at me explained it was night time he did nt have to yell others were tring to sleep 'Hell they are they arent asleep you .....' started to kick and hitting this nurse about face and kicked me in the stomack. gave syprexa 5 mg. injection into RT. gluteus at 11:30 p.m."" Review of the March 2011 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the resident's care plan, developed on 03/15/11, found it addressed the resident's behaviors of cursing at staff and combative / threatening behaviors. Interventions included to always ask for help if the resident became abusive / resistive and remove from public area when behavior was unacceptable. Review of multidisciplinary notes found no documentation indicating these interventions in the care plan were used before giving the resident antipsychotic drugs for which he had no diagnosis. There was also no intervention to assess the resident for pain or discomfort as a possible underlying cause of the behaviors. In an interview on 08/15/11 at 3:30 p.m., the director of nursing (Employee #6) confirmed the use of [MEDICATION NAME] IM was not appropriate. .",2014-12-01
10830,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-08-16,329,D,1,0,XG6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of product information via the Internet (WebMD), and staff interview, the facility failed to ensure the medication regimen of one (1) of six (6) sampled residents was free of unnecessary medications. Staff administered to Resident #67 an antipsychotic medication ([MEDICATION NAME]) via intramuscular injection (IM) for agitation on an ""as needed"" (PRN) basis without adequate indications for use and at a frequency (PRN) that was not consistent with manufacturer's recommendations. According to product information from the manufacturer, the use of [MEDICATION NAME] is not recommended for treatment in the elderly with dementia-related [MEDICAL CONDITION] due to an increased risk of death. The product information also indicated only the daily use of [MEDICATION NAME]; there was no indication that PRN use of this medication was recommended. Review of physician progress notes [REDACTED]. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review disclosed this [AGE] year old male resident, who was initially admitted to this facility on 02/21/11, had medical diagnoses that included multiple [MEDICAL CONDITION] with [MEDICAL CONDITIONS], diabetes, hypertension, [MEDICAL CONDITION] of the prostate with metastasis, dementia, gangrenous changes in his extremities, Stage 2 pressure ulcer on the coccyx, and recent bouts with pneumonia. Review of the multidisciplinary notes disclosed the resident had been sent out to the hospital for acute medical problems and returned to the facility on [DATE]. The notes revealed that, shortly after returning to the facility, the resident began exhibiting behaviors of verbal and physical abuse toward staff and other residents at times. The notes also disclosed the resident was confused, non-ambulatory, and required assistance for most activities of daily living. Review of physician's orders [REDACTED]. In addition, [MEDICATION NAME] 0.5 mg PO (by mouth)/IM BID (twice daily) had been given on 03/16/11. Further review of multidisciplinary notes found [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for the resident being uncooperative with staff and cursing. The multidisciplinary note stated (quoted as written): ""Resident has been uncooperative cursing and call staff names and slapping at staff, tried to talk and redirect him to no avail. Gave syrexia 1ml. injection, into lt. gluteus.at 12:05AM.at 1:05AM resident calm asleep.will continue to check and monitor."" [MEDICATION NAME] IM was given again on 03/26/11 at 11:42 p.m. for yelling ""Help"", cursing, and being physically abusive toward staff. The multidisciplinary note stated (quoted as written): ""Resident yelling at top of his voice 'HELP' went to room he started calling this nurse names and cusing at me explained it was night time he did nt have to yell others were tring to sleep 'Hell they are they arent asleep you .....' started to kick and hitting this nurse about face and kicked me in the stomack. gave syprexa 5 mg. injection into RT. gluteus at 11:30 p.m."" Review of the March 2011 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the resident's care plan, developed on 03/15/11, found it addressed the resident's behaviors of cursing at staff and combative / threatening behaviors. Interventions included to always ask for help if the resident became abusive / resistive and remove from public area when behavior was unacceptable. Review of multidisciplinary notes found no documentation indicating these interventions in the care plan were used before giving the resident antipsychotic drugs for which he had no diagnosis. There was also no intervention to assess the resident for pain or discomfort as a possible underlying cause of the behaviors. According to product information found on WebMD, the use of [MEDICATION NAME] is not recommended for treatment in the elderly with dementia-related [MEDICAL CONDITION] due to increased risk of death. The product information also indicated only the daily use of [MEDICATION NAME]; there was no indication that PRN use of this medication was recommended. Review of physician progress notes [REDACTED]. In an interview on 08/15/11 at 3:30 p.m., the director of nursing (Employee #6) agreed the PRN use of [MEDICATION NAME] was not the usual physician's orders [REDACTED].",2014-12-01
10831,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2009-09-16,279,D,0,1,LE6W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop a comprehensive care plan to address the assessed needs of two (2) of thirteen (13) sampled residents. A care plan was not developed to address the risk for dehydration and the use of [MEDICAL CONDITION] medications for Resident #26, and a care plan was not developed to address Resident #12's repeated urinary tract infections (UTIs) with E. coli. Facility census: 60. Findings include: a) Resident #26 1. Review of Resident #26's medical record, on 09/15/09, revealed the facility's decision to care plan for the risk of dehydration based on the results of a minimum data set assessment (MDS) with an assessment reference date 09/01/09. Review of the current care plan revealed the absence of a care plan directed at the risk of dehydration. During an interview on 09/15/09 at 4:00 p.m., Employee #25 said she thought they had fourteen (14) days to develop the care plan following the annual assessment. She returned at 4:30 p.m. with four (4) additional pages of care plan for Resident #26 with an initiation date of 09/15/09, which contained documentation addressing the area of dehydration risk. (See also citation at F327.) 2. Review of Resident #26's medical record revealed the facility's decision to care plan for the area of [MEDICAL CONDITION] drug use based on the 09/01/09 MDS. Review of the current care plan revealed the absence of a care plan for the problem area of [MEDICAL CONDITION] drug use. During an interview on 09/15/09 at 4:00 p.m., Employee #25 said she thought they had fourteen (14) days to develop the care plan following the annual assessment. She returned at 4:30 p.m. with four (4) additional pages of care plan for Resident #26 with an initiation date of 09/15/09, which contained documentation addressing the area of [MEDICAL CONDITION] drug use and risks. Medical record review with the director of nursing (DON) at this time revealed this resident had been on [MEDICAL CONDITION] medications since 2008 with pharmacy consultations and recommendations periodically since initiation of the drugs. The DON said it was clear they had forgotten to add this triggered area to the care plan. b) Resident #12 Medical record review disclosed this resident was incontinent of bowel and bladder. The resident's incontinence status had been assessed and a toileting program attempted, but the resident had refused to participate. Observations of the resident, on 09/14/09, found the resident was alert and oriented and able to voice preferences. Interviews conducted with direct care staff, on 09/14/09, revealed the resident preferred to stay in bed and used adult briefs for incontinence. Further review of the medical record on 09/14/09, revealed the resident was treated for [REDACTED]. E. coli is a bacteria found in feces; it enters into the urinary tract most commonly due to improper or delayed peri-care following incontinence. Review of the resident's care plan for UTIs, dated 07/15/09, found the plan failed to address interventions and staff education to prevent recurrent E. coli infections. In an interview on 09/16/09 at 12:15 p.m., the DON confirmed the care plan for UTIs did not adequately address the recurrent E. coli infections. .",2014-12-01
10832,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2009-09-16,327,D,0,1,LE6W11,"Based on record review, observation, and staff interview, the facility failed to follow their policy for hydration for a resident assessed as being at risk for dehydration. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #26. Facility census: 60. Findings include: a) Resident #26 Review of Resident #26's medical record, on 09/15/09, revealed the facility's decision to care plan for the risk of dehydration based on the results of a minimum data set assessment (MDS) with an assessment reference date 09/01/09. Review of the current care plan revealed the absence of a care plan directed at the risk of dehydration. During an interview on 09/15/09 at 4:00 p.m., Employee #25 said she thought they had fourteen (14) days to develop the care plan following the annual assessment. She returned at 4:30 p.m. with four (4) additional pages of care plan for Resident #26 with an initiation date of 09/15/09, which contained documentation addressing the area of dehydration risk. During interview with the dietary manager (Employee #8) on 09/16/09 at 10:00 a.m., she said she was unaware Resident #26 had triggered for dehydration risk. She reviewed the MDS tracking form and said another nurse (Employee #81) completed the dehydration assessment in place of the regular nurse, who was off on maternity leave at this time. She said when Resident #26 triggered for dehydration risk, the only way the facility would be able to assess and monitor the amount of fluid she consumed daily would be by maintaining an intake and output record, and this had not been done. During interview with Resident #26 on 09/16/09 at 10:20 a.m., she replied ""no"" when asked if she could pour a drink from the pitcher sitting on her over bed tray. At 10:25 a.m. on 09/16/09, Resident #26's nurse (Employee #19) stated staff did not record fluid intake and output on this resident, but they did encourage her to take fluids. During observation of Resident #26 taking medications on 09/16/09 at 10:35 a.m., Employee #19 stated this resident was unable to pour a drink from the pitcher on her table, and she normally had a special cup on her table with a straw in it that was obtained from the local hospital, but it was not here at this time. She said the resident shook too much to pour her own drinks and used a Kennedy cup for liquids with all meals. On 09/16/09, the director of nursing produced a copy of the facility's hydration policy. According to the ""10.6 Hydration"" policy, residents who are at risk for dehydration ""are referred to the Interdisciplinary Care Team for appropriate interventions"", and they are to ""Use a Hydration Protocol or Intake and Output form to monitor residents who are at risk of dehydration"". The director of nursing said that, after talking with other staff, she believed they may have missed this one.",2014-12-01
10833,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,156,C,0,1,L59911,"Based on observation and staff interview, the facility failed to post accurate information regarding the State licensure office. This practice had the potential to affect all facility residents. Facility census: 48. Findings include: a) Observation of facility postings, at 4:00 p.m. on 08/13/09, revealed the address for the Office of Health Facility Licensure and Certification (OHFLAC) was incorrect. Additionally the posting did not state that residents could file a complaint with OHFLAC, but stated that this was the agency to whom the residents should address ""appeal rights"". This was brought to the attention of the social worker (SW) at 4:05 p.m. on 0/13/09. The SW stated the posted information had just been revised and the wrong form must have been posted. .",2014-12-01
10834,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,225,D,0,1,L59911,"Based on review of the facility's complaint records and staff interview, the facility failed to assure one (1) incident of resident neglect involving two (2) licensed practical nurses (LPNs) was reported to the Office of Health Facility Licensure and Certification, Adult Protective Services, or the West Virginia Nursing Board. Resident identifier: #49. Facility census: 48. Findings include: a) Resident #49 Review of the facility's complaint records revealed that, on the night shift on 05/23/09, this resident was seated at the nurse's station. He was noted to be eating feces and had feces on his face, hands, and clothing. Two (2) LPNs (Employees #23 and #78) instructed a nursing assistant (NA - Employee #85) to clean up the resident. This was not done in a timely manner by the NA, yet neither LPN made an effort, themselves, to assure the resident was cleaned and could not then eat feces. The facility reported and disciplined the NA but did not report or address the fact that both LPNs had also neglected the resident by leaving the resident in feces for a long period of time. This information was brought to the attention of the social worker (SW) and director of nursing (DON) at 9:00 a.m. on 08/11/09. After discussion of the situation, both recognized that the LPNs should have also been reported and disciplined. .",2014-12-01
10835,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,250,D,0,1,L59911,"Based on medical record review, resident interview, and staff interview, the facility failed to identify the need for medically-related social services, and ensure the provision of these services, for one (1) of twelve (12) sampled residents. This resident could not hear, because she needed a new hearing aid battery. Resident identifier: #43. Facility census: 48. Findings include: a) Resident #43 Medical record review, on 08/12/09, revealed this resident was very hard of hearing and used a hearing aid. An interview with the resident, at 1:00 p.m. on 08/12/09, revealed the resident was having a very difficult time hearing, and she stated she could hear better if she was wearing her hearing aid. When asked if she would like to stop and put in the hearing aid, the resident reported, ""My battery's dead."" At 3:30 p.m. on 08/13/09, an interview was conducted with the social worker (SW) regarding batteries for the resident's hearing aid. The SW stated the resident's family was supposed to bring the batteries but had not yet done on. It was confirmed, at that time, that the facility needed to assure the resident's hearing aid was working. That same afternoon, an interview was conducted with a registered nurse (RN - Employee #9). The RN confirmed the facility did not have a plan in place to check the resident's hearing aid batteries to assure she always had a working hearing aid. .",2014-12-01
10836,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,329,D,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the drug regimen of one (1) of twelve (12) sampled residents was free of unnecessary medications. This resident was ordered an antipsychotic medication without first attempting non-pharmacological interventions to address targeted behaviors. Resident identifier: #41. Facility census: 48. Findings include: a) Resident #41 Medical record review, on 08/13/09, revealed this resident was admitted to the facility on [DATE]. On 04/28/09, the physician ordered [MEDICATION NAME] 0.5 mg twice daily for ""dementia with behaviors"". There was no evidence that factors causing or contributing to the behaviors were explored and no evidence of attempts at non-pharmacological interventions prior to the use of an antipsychotic medication. On 08/13/09 at 10:30 a.m., a registered nurse (RN - Employee #9) provided a behavioral monitoring form. Every intervention was ""talking"", ""explaining"", ""told"", etc. All interventions were pointing out to this resident with dementia that she was expected to stop whatever she was doing. There were no interventions to see if the resident needed anything, no interventions to determine if the resident was in distress, nothing to evaluate if this resident, who was new to the facility, was having adjustment difficulties, etc. At 1:45 p.m. on 08/13/09, Employee #9 confirmed there was no evidence of a change in interventions when attempted interventions were not working. Employee #9 also confirmed there was insufficient evidence that non-pharmacological interventions were attempted, and failed, prior to the decision to medicate the resident. .",2014-12-01
10837,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,371,F,0,1,L59911,"Based on observation, food temperature measurement, and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 48. Findings include: a) On 08/11/09 11:30 a.m., a dietary employee was observed scooping cereal into bowls from plastic boxes. The plastic cereal boxes were soiled inside and out. At the time of this observation, the dietary manager was present and confirmed the plastic boxes were soiled. b) At 11:35 a.m. on 08/11/09, bowls, cups, and plate covers were observed to be stacked inside of each other or inverted on trays prior to air drying. These items were observed with trapped moisture, creating a medium for bacterial growth. c) 08/12/09 at 8:30 a.m., cross contamination was observed during dish washing at the dish machine. The person who put soiled racks of dishes in the machine was also going to the clean side to remove clean dishes without washing her hands. This person also scraped paper from soiled trays with her hands, then collected and stacked the clean dishes without washing her hands. In addition, clean racks of dishes were being pushed through the dish machine with soiled trays of dishes. .",2014-12-01
10838,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,152,D,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the determination of capacity for a resident was made in accordance with Chapter 16, Article 30 of the West Virginia State Code, prior to allowing another individual to make health care decisions on behalf of the resident. The cause, nature, and duration of the incapacity were not identified for one (1) of the twelve (12) residents on the sample. Resident identifier: #28. Facility census: 48. Findings include: a) Resident #28 Review of the medical record for this resident found determinations of capacity dated 02/13/08 and 03/17/09. Both of the assessments identified the resident as lacking capacity to make health care decisions. The ""Physician's Determination of Capacity"" dated 02/13/08 had an ""X"" in the box by ""[MEDICAL CONDITION]"" in the section for ""Nature"". (""[MEDICAL CONDITION]"" means the resident was unable to speak but would not necessarily mean the resident was unable to communicate and/or make medical decisions.) In the section for the cause of the incapacity, ""ASCVD"" ([MEDICAL CONDITION] cardiovascular disease) had been written. Again, this [DIAGNOSES REDACTED]. Additionally, the box by the section indicating the resident had been informed that someone else would be making her health care decisions was not checked. On the same form, another section for ""Periodic Capacity Review"" had been completed on 03/17/09. An ""X"" had been placed in the box by ""Demonstrates INCAPACITY to make medical decisions."" It had not been marked to indicate the resident was informed of the decision, and nothing had been checked or written for the nature and cause of the incapacity. The West Virginia Health Care Decisions Act, ?16-30-7. Determination of incapacity., states: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10839,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,281,E,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of facility policies and procedures, and staff interviews, the facility failed to ensure medications were given as ordered and/or in accordance with accepted standards of practice. an order for [REDACTED]. Additionally, a nurse initialed the medication administration records (MARs) of multiple residents prior to administering their medications. Resident identifiers: #28, #38, #20, #12, #118, #79, #30, #5, and #21. Facility census: 48. Findings include: a) Resident #28 1. Review of the resident's medical record, on 08/14/09, found an order for [REDACTED]. (Nitro paste is most often used to treat [MEDICAL CONDITION].) A consult for the resident's ""2nd toe of Right Foot"" was found in the resident's medical record dated 07/12/09. The form had been completed by the consulting physician to include a recommendation for Nitropaste 1/2 inch to the foot. On 08/14/09 at 9:35 a.m., the treatment nurse (Employee #57), when asked how much of the paste she applied to the area, said she just smeared some on the resident's toe with her gloved finger. Employee #57 was informed of the recommended amount noted on the consult form. At approximately 10:30 a.m., a registered nurse (Employee #9) reported a clarification order had been obtained. The physician ordered one-half inch of the Nitro paste be applied to the top of the resident's right foot daily for [MEDICAL CONDITION]. 2. At 5:25 a.m. on 08/13/09, Employee #55 was observed giving the resident her medications via gastrostomy tube. The nurse disconnected the tubing and commented the resident had been receiving her tube feeding and she had checked the placement earlier in the shift. After disconnecting the formula tubing, she attached a syringe, flushed the tubing with water, and instilled [MEDICATION NAME] that had been crushed and mixed with water. According to page 30 of the facility's policy and procedure entitled, ""Administering Medication through a Gastric Tube"", step 17 instructed (in bold print): ""Check placement in the stomach and residual gastric contents: a. Attach 50 to 60 ml syringe containing approximately 10 cc air. b. Auscultate the abdomen.... c. Listen for 'whooshing' sound to check placement of the tube in the stomach. d. Pull back gently on the syringe to aspirate stomach content. e. If the stomach content can not be aspirated, pull back slightly on the tube to reposition.... f. If there is more than 100 ml of stomach content, withhold medication and notify the physician. g. If the resident is on continuous tube feedings, the stomach content should be no more than 50 percent of intake in the last hour. If so, withhold the medication and notify the physician...."" The nurse did not check placement by auscultation, nor did she check the amount of residual prior to administering the medication. c) Residents #38, #20, #12, #118, #79, #30, #5, and #21 Another nurse (Employee #23( was observed administering medications to the above-identified residents during the morning and/or evening medication passes on 08/13/09. The nurse initialed the MARs prior to administering the medications to the residents. On the morning of 08/14/09, the director of nursing was asked for a copy of the facility's policies and procedures regarding documentation of medications. The policy regarding scheduling of medications was silent as to when the administration of medications was to be documented. A copy of the ""Charting and Documentation"" was also provided. It did not specifically indicate when the administration of medications should be documented. However, the policy and procedure regarding ""Administering Medications through a Gastric Tube"" did include, under a heading of ""Documentation"", the information to be recorded in the resident's medical record which included: ""The drug name, dose, time, date, and route of administration. (Note: Such information should be documented on the resident's Medication Administration Record [REDACTED] Review of nursing fundamentals manuals found the following: 1. 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. Usually space is available for a full signature on the record. Documentation should be done after the client has received the drug."" 2. Nursing Fundamentals By Rick Daniels Under "" Safety Tips in Medication Administration "" - Do not leave any medications at the client ' s bedside - Immediately initial the medication record for the medications you have given. 3. Delmar (also see doc ""Delmar - Nursing Documentation"") Online Companion: Nursing Fundamentals: Caring & Clinical Decision Making ""Effective documentation requires the use of common vocabulary; legibility and neatness; the use of only authorized abbreviations and symbols; factual and time-sequenced organization; and accuracy, including any errors that occurred. Medication errors should be recorded on incident reports, the Medication Administration Record [REDACTED]. All documents related to client care are confidential and clients must sign a release to have their information released, specifying what type of information may be released and to whom it may be released."" 4. Fundamentals of Nursing By Sue Carter DeLaune, Patricia Kelly Ladner ""Chart in a timely fashion to avoid the omission of pertinent data; it is not a good practice to wait until the end of the shift to chart on all the clients. Chart medications immediately after administration to avoid errors. Sign your name after each entry."" .",2014-12-01
10840,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,332,E,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration pass, reconciliation of the observed medication administration with medical records, and staff interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. Nurses administered multivitamins to three (3) residents who had orders for multivitamins with minerals. This resulted in a medication error rate of seven percent (7%). Resident identifiers: #20, #29, and #38. Facility census: 48. Findings include: a) Residents #20, #29, and #38 During observation of morning medication pass on 08/13/09, three (3) residents (#20, #29, and #38) were given a multivitamin, although the orders on their medication administration records (MARs) specified a multivitamin with minerals. This resulted in three (3) errors being detected when the observed medication administration was reconciled with the residents' medical records. Additional medication passes were observed until a total of forty-two (42) opportunities had been observed. This yielded an error rate of seven percent (7%). The errors were as follows: 1. A nurse (Employee #23) gave Resident #20 a multivitamin. The resident had had an order for [REDACTED]. 2. Employee #23 gave Resident #38 a multivitamin, although the physician's orders [REDACTED]. 3. Another nurse (Employee #29) gave Resident #35 a multivitamin. The resident had had an order for [REDACTED]. b) At approximately 3:30 p.m. on 08/13/09, the stock medications were observed in a cabinet in the medication room with Employee #23. It was found there were bottles of Thera-M in the cabinet. The labels of the bottles from which the multivitamins were given to the three (3) residents that morning and the Thera-M were compared. The components of the two (2) vitamins were significantly different. .",2014-12-01
10841,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,441,E,0,1,L59911,"Based on observations and review of facility policies and procedures, the facility failed to ensure staff employed infection control practices to prevent the spread of infection. Handwashing was not performed in accordance with the facility's policy and procedure; scissors used in the performance of treatments were taken and returned to the nurse's pocket without being cleaned; a nurse did not wash her hands prior to donning gloves to administer eye drops; and common use items, once contaminated, were returned to general storage in the treatment cart. Additionally, the infection control program did not include a full description of how handwashing was to be performed in accordance with Centers for Disease Control and Prevention (CDC) Guidelines. This deficient practice has the potential to affect all residents. Resident identifiers: #28, #27, #6, and #48. Facility census: 48. Findings include: a) Handwashing The facility's policy and procedure entitled ""Hand Hygiene"" included: ""Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water. ..."" It also noted, ""The use of gloves does not replace handwashing / hand hygiene."" The policy and procedure did not fully instruct staff how perform handwashing in accordance with CDC guidelines. The CDC recommends: ""B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (CDC recommendations for hand hygiene)"" The following deficits in the performance of handwashing were noted: 1. Resident #28 On 08/13/09, at approximately 5:30 a.m., after administering medications via gastrostomy tube, the nurse (Employee #55) removed her gloves and washed her hands at the sink in the resident's room. She washed her hands for approximately two (2) seconds and then turned off the faucet with her bare hands. 2. Resident #27 After administering medications to the resident at approximately 5:32 a.m. on 08/13/09, Employee #55 washed her hands at the sink in the resident's room. She again washed her hands for approximately two (2) seconds and then turned off the faucet with her bare hands. 3. Resident #6 On 08/13/09 at 5:55 a.m., Employee #55 was observed giving eye drops to Resident #6. After having had contact with the medication cart, various medications in the drawer while locating the resident's eye drops, and environmental objects, the nurse donned gloves and administered eye drops to the resident without first having washed her hands. b) Treatment technique On 08/12/09 at 4:40 a.m., a nurse (Employee #57) was observed changing a dressing on Resident #48's left lower leg. She donned gloves and removed the ace bandage that was over the dressing. She retrieved scissors from her pocket while wearing the same gloves, cut the old dressing off, then returned the scissors to her pocket. This created a potential for transfer of microorganisms from the nurse's pocket to the resident and from the resident to the nurse's pocket. After removing her gloves, the nurse washed her hands at the sink for approximately two (2) seconds. After completing the dressing to the left leg, the nurse changed the dressing on the resident's right leg. She again took the scissors out of her pocket, cut off the old dressing, and returned the scissors to her pocket. The nurse also placed tape in her pocket, which was then returned for common use to the treatment cart after the treatment was completed. .",2014-12-01
10842,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,309,D,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review of medical records, the facility failed to ensure each resident was positioned to promote the individual's highest practicable level of physical well-being. Two (2) residents were observed to not be positioned in a manner to maintain good body alignment and to promote safety while eating and taking medications. Resident identifiers: #30 and #44. Facility census: 48. Findings include: a) Resident #30 1. At lunch time on 08/13/09, the resident was observed eating while in bed. The head of her bed was elevated at approximately 50 degrees. She had slid down in the bed and had to lift her shoulders off of the bed to reach items on her tray. The [MEDICATION NAME] area of her back was in the bend of the bed. She was noted to cough periodically. Review of the resident's medical record found she had been evaluated by the speech therapist and received the services of the therapist from the latter part of June 2009 through the first part of August 2009. She had been identified as being at risk of aspiration and choking. On 08/09/09, the physician had ordered the resident to be up in a geri chair as tolerated for meals for ""dysphagia"" (difficulty swallowing). The positioning of the resident did not facilitate ease of eating, nor did it promote safety, i.e., reduce the likelihood of choking / aspiration and enhance the passage of food through the esophagus. 2. At approximately 5:10 p.m. on 08/13/09, a nurse (Employee #23) was observed giving the resident Tylenol for complaint of her feet hurting. The resident had slid down in the bed so that her scapula were in the bend of the bed and her neck was flexed forward. The resident was not repositioned before the medication was administered, nor afterward. b) Resident #44 A lunch time on 08/13/09, the resident was observed sitting up in a recliner with a pillow behind her head. The chair was not upright during the meal. Before, during, and after lunch, the resident was observed to have slid down in the chair and her body was in poor alignment. .",2014-12-01
10843,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,174,D,0,1,ZHEQ11,". Based on resident interview, staff interview, and record review the facility failed to allow one (1) of thirty-two (32) Stage II sampled residents to make personal phone calls in a private area where she could not be overheard. Resident identifier: #84. Facility census: 95. Findings include: a) Resident #84 During an interview on 02/02/10 at 11:00 a.m., Resident #84 stated she was only allowed to make one (1) phone call each week to her son, and she had to make that phone call in the social worker's office with the social worker present. When questioned as to why she thought she could not make a private call, the resident stated she did not know. The resident's hard copy medical record located at the nurses' station, when reviewed on 02/08/10 at 1:00 p.m., contained a note taped to the inner front cover of the record which stated the resident was to make her phone calls from the social worker's office; the note also identified one (1) individual she was not to receive calls from at all. The resident's care plan, when reviewed, made no mention of these phone restrictions, the reason for the restrictions, or the expected outcome of the restrictions. On the afternoon of 02/08/10, a facility social worker (Employee #80), when interviewed related to these phone restrictions, stated that, at one time, the resident was taking advantage of phone use and making too many calls. At that time, it was decided that her access to telephone privileges be limited. Since that time, the problem had resolved, and the resident could now make calls when she chose. She further stated the resident had her own cell phone which required her to pay for the addition of call minutes, but she could use it anytime she wanted to. The social worker further agreed the phone restrictions had never been part of her care plan and the note on her medical record had not been removed to allow the resident privacy with her phone calls. .",2014-12-01
10844,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,241,E,0,1,ZHEQ11,". Based on observation and staff interview, the facility failed to assure dignity during dining. Plates were stained, the dining rooms were institutional in appearance, and the residents were served in an institutional manner. Additionally, one (1) of thirty-two (32) Stage II sampled residents (#35) was served her meal in an institutional fashion and was not positioned to facilitate ease of eating. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 95. Findings include: a) During the evening meal at 5:30 p.m. on 02/01/10, observations of the residents' dining areas found them to be institutional in appearance. The residents were served on tables without tablecloths or any other adornments to make the dining experience attractive and homelike. Additionally, the residents' meals were brought on trays and left on the trays on the tables. The plates were on insulated plate warmers, and these were also left on the tables. b) Observation of meal service, at noon on 02/09/10, revealed the plates used for meal service were so badly stained, they appeared soiled. This was brought to the attention of Employee #103, who was filling in for the dietary manager. Employee #103 confirmed the plates were in poor condition and that their use did not promote dignity for the residents. c) Resident #35 During the evening meal on 02/01/10, observation found Resident #35 in the dining room for unit B1. The resident's meal was placed before her, but her plate was not taken off of the tray. The lid to keep the food warm was also left on the table. This also occurred during the noon meal on 02/11/10. Observation also found Resident #35 seated in a low wheelchair placed at the table so that she was about six (6) inches below the top of the table; her positioning interfered with her ability to reach her food. This also occurred during the evening meal on 02/01/10, and during the noon meal on 02/02/10. .",2014-12-01
10845,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,364,E,0,1,ZHEQ11,". Based on observations, taste testing, policy review, and staff interview, the facility failed to assure foods were prepared and held by methods which conserved nutritive value and flavor, failed to assure foods were well seasoned, failed to assure bananas were edible, and failed to assure pureed foods were attractive. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 95. Findings include: a) On 02/01/10 at 5:30 p.m., an observation was made of the GORE 2 evening meal. During this time, the bananas which were served were noted to be very green (not ripe), and residents were unable to peel them. b) At 5:30 p.m. on 02/01/10, during observations of meal service on GORE 2, GORE B and GORE C, the foods for the residents who required pureed diets were not thick enough to have a form. They were thin and ran together on the plates. In addition, the pureed foods foods were nearly the same color and were not appetizing in appearance. c) During observation of the noon meal, on 02/09/10, pureed spaghetti was not thick enough to have a form. It ran into other foods on the plates. d) Taste testing of foods, at noon on 02/10/09, revealed the foods which were prepared in smaller amounts did not taste as though they contained seasoning. Upon inquiry, Employee #11 stated she added salt to the main menu items, but she did not add salt to foods prepared for substitutions or preferences because ""some of the residents can't have salt."" e) During observation of the noon meal on 02/09/10, an inquiry was made regarding the time the foods had been place on the steam table. Employee #11 stated they were placed on the steam table at 10:00 a.m. The service of the noon meal was not to begin until 11:00 a.m. Prolonged holding of foods on the steam table has the potential to impact the nutritional value and flavor of foods. Review of the dietary policy and procedure manual revealed there were no directives for the length of time foods should be held on the steam table. f) Observation, at noon on 02/09/10, revealed no use of garnishes or other means to make the meals attractive. When asked if garnishes were ever used, Employee #11 stated, ""When the dietitian is here."" When asked when they should be using garnishes, the dietary staff present stated, almost in unison, ""All the time."" .",2014-12-01
10846,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,371,F,0,1,ZHEQ11,". Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 95. Findings include: a) During the initial tour of the dietary department on 02/01/10, observation found food service items stacked inside each other and/or inverted on trays prior to air drying. Moisture was trapped inside of the food service items, creating a medium for the growth of bacteria. This was also observed during observation of the dietary department at noon on 02/09/10. At that time, this was discussed with Employee #103, who was filling in for the dietary manager. Employee #103 stated staff was aware all items had to be air dried prior to stacking or inverting on trays. b) At noon on 02/09/10, observation in the kitchen found coffee cups upright on trays with a second tray on top; this second tray was intended to protect the cups from contamination. These trays did not fully cover the cups and had slid entirely off some of the cups. In addition, the inside of the coffee cups contained debris which could be scraped off with a fingernail. These sanitation infractions were confirmed by Employee #103, at that time. c) At noon on 02/09/10, Employee #103's hair restraint was not fully restraining her hair. When this was brought to her attention, she confirmed the situation and correctly applied her hair net. In addition, Employee #103 was wearing a shirt with sparkles which were coming off onto her skin and clothing. Upon inquiry, Employee #103 stated she had cooked that morning. The loose sparkles had a potential to contaminate the food products which Employee #103 had prepared. d) When temperatures of foods on the steam table were measured by Employee #11, she did not sanitize the thermometer between each food. This practice had the potential to result in a spread of bacteria and/or other infectious organisms from one (1) food to the other. e) The concentration of the sanitizing solution in the three (3) compartment sink, at which pots and pans were being washed at noon on 02/09/10, was tested . It did not reveal the presence of any sanitizing agent. In an interview with Employee #90, who had filled the sinks, this employee described filling the sink, then adding a few pumps of the sanitizing agent to the water. When asked how many pumps he should be adding, he stated he did not know. He stated it was a new product, and no one had instructed dietary personnel in its use. Employee #103 was asked to contact the supplier of the sanitizing agent for information regarding how the product was supposed to be used. At 2:00 p.m. on 02/09/10, Employee #103 reported the sanitizing agent was set up to mix while the sink filled. If used correctly, the water and sanitizing agent would mix, in the correct concentration, as the sink filled. No one in the dietary department was aware of this process. f) The finish had worn off the plates used to provide meals to the residents. This resulted in the plates being porous and highly susceptible to contamination. In this condition, it was no longer possible to properly sanitize the plates. g) At noon on 02/09/10, Employee #90 was observed washing his hands. He washed and rinsed his hands, dried them with paper towels, then turned off the faucet with paper towels. After turning off the faucet, he dried his hands again with the paper towels with which he had turned off the faucet. This resulted in contamination of his hands. .",2014-12-01
10847,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,492,C,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and review of individual food service workers' permits, the facility failed to fully comply with local laws regarding food handler's cards. One (1) of twenty-eight (28) current dietary employees had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all residents who received nourishment from the dietary department. Employee identifier: #178. Facility census: 95. Findings include: a) On [DATE], each current dietary employee's food handler's card was reviewed. No card was available for Employee #178. The administrator (Employee #19) was asked to determine if Employee #178 had a current food handler's card. During the afternoon of [DATE], the administrator reported Employee #178's food handler's card had expired and she would no be working in the dietary until she had obtained a new food handler's card.",2014-12-01
10848,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,223,D,0,1,ZHEQ11,". Based on medical record review and staff interview, the facility failed to ensure each resident was free from involuntary seclusion for one (1) of thirty-two (32) Stage II sampled residents. Staff developed a progressive behavior modification plan which included confining Resident #29 to his room. This plan required staff to document antecedents to the target behavior, staff's response to he behavior, what consequence was applied, and the resident's response to the consequence. The imposition of involuntary seclusion was not implemented in accordance with the behavior modification plan. Facility census: 95 Findings include: a) Resident #29 Record review revealed a problem statement within Resident #29's care plan, dated 11/24/09, stating: ""Behavior Protocol: Episodes of inappropriate behavior as demonstrated by voiding on multiple sets of his clothing throughout the day...also has a behavior plan that addresses instances where he voids on his clothing."" Interventions associated with this care plan included a ""Psychosocial Program"". According to this program, on each shift, ""the first time that (Resident #29) voids on his clothing, he will be provided with a change of clean clothes. Staff are to inform that the next time he voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids inappropriately for the second time on his clothes, he will be dressed in a gown. Hospital policy stated that if a resident is wearing a gown, they must stay in their room until properly dress. (Resident #29) will be given a clean set of clothes at the start of the next shift."" On the mid-afternoon of 02/09/10, interview with the psychological assistant revealed this resident's behavior was tracked on behavior monitoring sheets. She indicated the resident had a behavior management plan now in place to reward positive behaviors, and the psychological assistant related the behavior protocol described above originated on 05/28/07 and was discontinued on 10/17/07. She said the resident again began voiding on his clothing purposefully around November 2009, and the behavior protocol was put back into place. Additional information was requested at this time. On the early afternoon of 02/11/10, the psychological assistant presented tracking sheets for Resident #29. On the sheet, instructions stated, ""What was the negative behavior? What brought it on? How did your respond?"" Review of the tracking sheets from 11/02/09 through 02/11/10 found descriptions of the resident's behavior, but there was no discussion of what brought on the behaviors and/or how staff responded when the resident removed his clothing and urinated on it. Also not noted were the resident's responses to staff interventions. A psychological behavior plan note, dated 11/24/09, stated, ""Informed (Resident #29) that a new behavior protocol would be started for his inappropriate voiding behaviors. I explained to him that if he voided on his clothes he would get one clean set and after that he would be in a gown. I also told him that once he was in a gown he needed to stay on the unit and would have his meals on the floor and miss any activity going on at that time. Once the new shift came on he would receive new set of clothes. He asked me questions and I answered... Later on this evening staff informed this writer that (Resident #29) became upset because he said that I told him he was to eat on the floor. Staff tried to tell (Resident #29) that was only if he was in a gown. He continued to argue with staff and went to bed."" Confidential staff interviews, on 02/09/10 at 4:00 p.m. and 02/09/10 at 10:00 a.m., found that, if the resident inappropriately voided once, he was supposed to get another set of clothing. If the resident voided a second time, he would then be put into a hospital gown and brief and placed in his room until the next shift came on. He would not be allowed out of his room until the next shift, at which time he would receive another set of clothing. Both the staff members interviewed reported this protocol was implemented at least once since November 2009. Review of the behavior tracking sheets failed to find any evidence of the resident's reaction to the implementation of the behavior protocol. Review of the psychological assistant's notes for the time period from 11/24/09 through 02/11/10 did not find any description of the resident's response to the behavior protocol when implemented. An attempt to interview Resident #29, on the late afternoon of 02/09/10, was unsuccessful. Psychological notes, dated 11/24/09, 12/04/09, 12/11/09, 01/08/10, 01/22/10, and 02/05/10, documented how many episodes of inappropriate voiding occurred, but there was no mention of how staff intervened and/or how the resident responded to the interventions. The resident also had a behavior management plan that rewarded the resident for good behavior, but the tracking sheets, when reviewed, did not indicate the resident's response when he was not rewarded. The behavior management plan indicated the resident voided inappropriately, but it did not include the behavior protocol that isolated the resident. On the mid-morning of 02/11/10, staff provided a plan of care evaluation, dated 02/10/10, which stated, ""Behavior of inappropriate voiding was brought up at the care plan meeting and staff reported that it has not been a problem recently. Team decided and agreed that it would be appropriate to resolve plan of care for this behavior."" .",2014-12-01
10849,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,441,F,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on policy review, staff interview, and observation, the facility failed to establish and implement an infection control program designed to provide a sanitary environment to prevent the potential spread of infections. This deficient practice was noted through observations in the dietary department of improper handwashing technique; during policy and procedure review; having no distinct policy and procedure regarding how to care for a resident with a specific blood-borne pathogen; having no distinct policy and procedure regarding various types of isolation for staff to consult and follow; having an outdated handwashing guideline in the infection control policy and procedure manual; and lack of gastrointestinal infection monitoring since March 2009. These deficient practices had the potential to affect all residents residing in the facility. Facility census: 95. Findings include: a) Review of the infection control (IC) manual, with the IC nurse (Employee #130) on 02/10/10 at 9:30 a.m., found there were no distinct instructions for primary types of isolation for staff to refer to for Airborne Precautions (for such illnesses as [DIAGNOSES REDACTED], chickenpox, shingles, etc.). Also, the Droplet Precautions protocol was brief and noted only ""Standard Precautions plus"" private room (if available), wearing a mask within three (3) feet of the infected person, limiting movement to essential purposes only - mask patient or as indicated. Additionally, the IC manual's hand-washing policy listed an outdated procedure for lathering fingers and hands with friction for at least ten (10) seconds. The IC nurse stated that, when the need for isolation is identified, she would call the doctor with pertinent data and he would give the order to initiate isolation. The physician also would give the order to discontinue the isolation. She agreed that specific step-by-step instructions for nursing personnel to follow for Airborne, Droplet, and Contact Precautions would be good to have in the IC manual, especially in the event she might be absent when an isolation set-up is required. Both the IC nurse and the administrator acknowledged the IC manual should be reviewed and updated. They noted the IC policies and procedures were reviewed annually and the former IC nurse recently resigned in 2009. b) Review of the facility's documentation related to surveillance and tracking of infectious diseases, on 02/09/10 at 11:00 a.m., revealed there was no tracking for gastrointestinal infections within the facility. The IC nurse said nursing staff completed 24-hour reports, on which they recorded the names of residents with episodic vomiting and diarrhea, and she was aware of one (1) resident this month who had vomiting one (1) day and of another resident who had diarrhea briefly one (1) day this month. She said the facility has had no outbreaks in the past half year, and she was in contact with the local health department weekly when they call the facility to see if there are any problems with infection. The IC nurse agreed it would be good to keep track of gastrointestinal ailments and spoke of plans to begin collecting that data for tracking and trending purposes and for reporting to the quality assurance committee quarterly. On 02/10/10 at 10:00 a.m., the IC nurse produced a gastroenteritis tracking form she found which the facility had used through March 2009 and for some reason had discontinued it. c) Review of the IC manual revealed there was no written policy regarding instructions for staff to follow relating to care needs and precautions for a resident residing in the facility with a specific blood-borne pathogen. During an interview with the IC nurse on 02/10/10 at 9:30 a.m., she produced the IC policies and procedures manual she uses and agreed the policies and procedures in the manual need to be revised to enable nursing staff to know step-by-step how to handle various types of IC measures. During an interview with the administrator 02/10/10 shortly after 9:30 a.m., she acknowledged the current policy and procedure manual did not give concrete instructions for nursing staff to follow, and there was nothing specific to guide nursing regarding care and precautions for a resident with this type of blood-borne pathogen other than the standard precautions used for all residents. During an interview with a nurse (Employee #136) on 02/11/10 at 12:30 p.m., she stated guidelines to follow for this type of situation for the blood borne pathogen is in a big white book and she did not know why it wasn't in the IC policy and procedure manual. Interview with two (2) nursing assistants (Employee #142 and #149), on 02/11/10 at 1:05 p.m., revealed they were aware of the resident having a blood-borne pathogen and precautions to take, even though this information was not written in the assignment book to guide the health care workers. The nursing assistants said everyone who worked on that hall should already know of the blood-borne pathogen and, for example, should already be aware of precautions, such as not to use a regular razor on him when shaving. They acknowledged that the need to use an electric razor when caring for this resident was not written on the health care worker's assignment sheet, nor was there a notice on the assignment sheet instructing staff to use standard precautions when providing care. d) During an observation on 02/09/10 at 12:00 p.m., a dietary employee (Employee #90) washed his hands, obtained a clean paper towel with which to turn off the faucets, then proceeded to dry his hands with the same towel used to turn off the faucets, thereby contaminating his hands. This deficient practice was relayed to his immediate supervisor by the surveyor; it was also reported to the administrator during the exit conference on 02/11/10. .",2014-12-01
10850,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,250,D,0,1,ZHEQ11,". Based on resident interview, staff interview, and medical record review, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sampled residents. Resident #71 complained of problems with her roommate, but this was not adequately addressed. Resident #2 complained of several social services related issues and did not feel that these were addressed. Facility census: 95. Findings include: a) Resident #71 During an interview on 02/01/10 at 4:00 p.m., Resident #71 related she was recently moved to the room she in which she currently resided. Subsequent to the move, she was not sure what happened to some of her personal items. Included in these items was a lock box containing money. On 02/04/10 at 3:30 p.m., the social worker (Employee #150), when interviewed, related she did not know anything about a lock box. On 02/09/10 at 4:00 p.m., the social services director was told about the resident's concerns. On the late morning of 02/11/10, the social services director reported having found the resident's lock box in her closet, obscured from view. A statement from a social worker (Employee #80), dated 02/09/10, stated, ""As far as I can recall (Resident #71) did not have a lock box. I did not give (Resident #71) $10 for her to keep. If she had $10 she kept it with her. I never saw (Resident #71) have $10 either."" b) Resident #2 On 02/01/10 at 3:00 p.m., the resident was observed in her bed during the afternoon. The resident's curtain was drawn, separating her from her roommate. The resident was observed in bed with the covers drawn over her head. During an interview on 02/02/10 at 12:30 p.m., the resident related she moved into the room recently and her roommate cursed quite frequently. She said she talked with staff about it, but she had not received any response. On 02/04/10 at 3:30 p.m., Employee #150, when interviewed, reported she did not know anything about Resident #2's concern with her roommate. On 02/11/10 in the mid-morning, staff provided a copy of a social service progress note dated 02/10/10, which stated, ""Talked to (Resident #2) about reports that she can't sleep at night because of her roommate noise. Asked her if she wanted to move, she said she might sleep better. Asked her who her roommate was talking to that would keep her up and ... said staff. She said they 'carry on'. Asked her if it would work if I just asked staff to be quiet with (name of roommate) when (Resident #2) was in bed and she said yes."" .",2014-12-01
10851,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,309,G,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of thirty-two (32) Stage II sampled residents, to ensure nursing staff conducted a thorough assessment of a resident immediately following a fall. Staff then ambulated the resident, resulting in reports of pain. Staff reassessed her by doing ""pelvic rocks"", resulting in increased reports of pain (actual harm). Resident identifiers: #21. Facility census: 95. Findings include: a) Resident #21 Medical record review, on 02/09/10, disclosed a document titled Hopemont Hospital Resident Incident / Accident Report dated 01/21/10 at 2:25 a.m., which contained information related to a fall sustained by Resident #21. Entries on the report stated: - ""Incident (describe what happened): Unknown cause of fall, health service worker (HSW) responded to resident yelling."" - ""Resident response / reactions and consequences (included protocol): Assessment of resident while on floor. Reassessed upon c/o (complaint) hurting to walk, then reassessed in bed. Resident was cooperative with each assessment."" Review of the nursing progress notes, dated 01/21/10, revealed the following entry: ""Did an assessment on resident at that times no apparent injuries. Resident was able to stand with 2 person assist. Began to ambulate, at that time resident began stating that it hurts and she could not do it (walk to chair). We stood her at nurses station and did a more thorough assessment. No bruises, redness or enema noted at that time. Resident continued to favor her left side. We placed her in chair and took her to room. At that time (staff member's name) began assessing her by doing pelvic rocks and check external rotation and length of loere (sic) limb. During assessment resident began to c/o (complaint) more pain and even upon subject change during communication once area was pressed the resident immediately responded by stating stop, that hurts..."" During an interview on 02/11/10 at 2:45 p.m., the director of nursing (Employee #52) and the assessment coordinator (Employee #105) disclosed, ""They should not have done that (ambulated her without assessment) and definitely should not have done pelvic rocks."" Employee #52 disclosed this probably increased her pain following the fall, especially since the resident had a history of [REDACTED]. .",2014-12-01
10852,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,280,D,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to revise when necessary the care plans of three (3) of thirty-two (32) Stage II sampled residents. Resident #29's care plan was not revised when involuntarily seclusion to address problem behaviors was no longer used. Resident #60's care plan was not revised to address the use of hipsters and the administration of nutritional supplements. Resident #75's ability to self-perform certain activities of daily living declined, but the care plan was not updated to reflect the resident's new need for a wheelchair and a manual lift. Facility census: 95. Findings include: a) Resident #29 Record review revealed a problem statement within Resident #29's care plan, dated 11/24/09, stating: ""Behavior Protocol: Episodes of inappropriate behavior as demonstrated by voiding on multiple sets of his clothing throughout the day...also has a behavior plan that addresses instances where he voids on his clothing."" Interventions associated with this care plan included a ""Psychosocial Program"". According to this program, on each shift, ""the first time that (Resident #29) voids on his clothing, he will be provided with a change of clean clothes. Staff are to inform that the next time he voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids inappropriately for the second time on his clothes, he will be dressed in a gown. Hospital policy stated that if a resident is wearing a gown, they must stay in their room until properly dress. (Resident #29) will be given a clean set of clothes at the start of the next shift."" On the mid-afternoon of 02/09/10, interview with the psychological assistant revealed this resident's behavior was tracked on behavior monitoring sheets. She indicated the resident had a behavior management plan now in place to reward positive behaviors, and the psychological assistant related the behavior protocol described above originated on 05/28/07 and was discontinued on 10/17/07. She said the resident again began voiding on his clothing purposefully around November 2009, and the behavior protocol was put back into place. Additional information was requested at this time. On the early afternoon of 02/11/10, the psychological assistant presented tracking sheets for Resident #29. On the sheet, instructions stated, ""What was the negative behavior? What brought it on? How did your respond?"" Review of the tracking sheets from 11/02/09 through 02/11/10 found descriptions of the resident's behavior, but there was no discussion of what brought on the behaviors and/or how staff responded when the resident removed his clothing and urinated on it. Also not noted were the resident's responses to staff interventions. A psychological behavior plan note, dated 11/24/09, stated, ""Informed (Resident #29) that a new behavior protocol would be started for his inappropriate voiding behaviors. I explained to him that if he voided on his clothes he would get one clean set and after that he would be in a gown. I also told him that once he was in a gown he needed to stay on the unit and would have his meals on the floor and miss any activity going on at that time. Once the new shift came on he would receive new set of clothes. He asked me questions and I answered... Later on this evening staff informed this writer that (Resident #29) became upset because he said that I told him he was to eat on the floor. Staff tried to tell (Resident #29) that was only if he was in a gown. He continued to argue with staff and went to bed."" Confidential staff interviews, on 02/09/10 at 4:00 p.m. and 02/09/10 at 10:00 a.m., found that, if the resident inappropriately voided once, he was supposed to get another set of clothing. If the resident voided a second time, he would then be put into a hospital gown and brief and placed in his room until the next shift came on. He would not be allowed out of his room until the next shift, at which time he would receive another set of clothing. Both the staff members interviewed reported this protocol was implemented at least once since November 2009. Review of the behavior tracking sheets failed to find any evidence of the resident's reaction to the implementation of the behavior protocol. Review of the psychological assistant's notes for the time period from 11/24/09 through 02/11/10 did not find any description of the resident's response to the behavior protocol when implemented. An attempt to interview Resident #29, on the late afternoon of 02/09/10, was unsuccessful. Psychological notes, dated 11/24/09, 12/04/09, 12/11/09, 01/08/10, 01/22/10, and 02/05/10, documented how many episodes of inappropriate voiding occurred, but there was no mention of how staff intervened and/or how the resident responded to the interventions. The resident also had a behavior management plan that rewarded the resident for good behavior, but the tracking sheets, when reviewed, did not indicate the resident's response when he was not rewarded. The behavior management plan indicated the resident voided inappropriately, but it did not include the behavior protocol that isolated the resident. On the mid-morning of 02/11/10, staff provided a plan of care evaluation, dated 02/10/10, which stated, ""Behavior of inappropriate voiding was brought up at the care plan meeting and staff reported that it has not been a problem recently. Team decided and agreed that it would be appropriate to resolve plan of care for this behavior."" b) Resident #60 1. The care plan for Resident #60, when reviewed on 02/08/09, disclosed on page 6, under the column problems / strengths, that the resident ""wears hipsters at all times to prevent injury"". On 02/09/10 at 10:50 a.m., in an interview with the nurse on Unit 2A (Employee #72), the nurse was asked how the health service worker assigned to this resident would be aware that she needed hipsters at all times. This employee stated the information would be found documented on the ""aide assignment"" sheet. A copy of this document, when provided and reviewed, contained no reference of the need for hipsters at all times for this resident. Employee #72 then stated she did not know how the health service worker would be aware of this need. A health service worker providing care for this resident on 02/09/10 at 10:50 a.m. (Employee #142), when questioned related to the use of hipsters for this resident, reported she did not know if the resident needed hipsters. The employee stated, ""She (Resident #60) doesn't fall often, but she has fallen."" This employee then asked permission from the resident to check for hipsters and determined the hipsters were not in place. A registered nurse (RN - Employee #136) was questioned, on 02/09/10 at 3:00 p.m., as to why the resident had no hipsters in place, yet the care plan stated they were necessary. Employee #136 stated the care plan was inaccurate, and the hipsters had been determined not necessary some weeks prior. 2. Review of physician's orders [REDACTED].@ (at) 10 a., 3 p, and 8 p snack."" Review of a physician progress notes [REDACTED]. Her most recent weight, on 12/18/09, was 121#, which was down from 123.6# the previous month. On 12/18/09, the physician wrote he wanted the resident to receive Ensure three (3) times daily between meals to address nutritional issues and weight loss. The clinical nutrition assessment, dated 08/24/09, stated this resident's ideal body weight range was from 120# to 150#. Review of Resident #60's current care plan revealed she required a mechanical soft diet with pureed meats due to a chewing problem, and she required a therapeutic diet of No Concentrated Sweets, No Added Salt, and Low Cholesterol diet. However, the care plan was not revised to include the addition of Ensure three (3) times daily. This finding was discussed with the administrator at approximately 9:30 a.m. on 02/10/10. She noted they were aware the care plans should be more specific and have been working on that issue and would continue to do so. d) Resident #75 Review of the medical record, on 02/08/10, disclosed that, on 01/29/10, Resident #75 experienced some difficulty walking, and the physician ordered the use of a reclining chair for locomotion and comfort due to weakness. Observation of Resident #75, on the afternoon of 02/08/10, found her resting in a reclining chair at the nurses' station. During an interview on 02/11/10 at 10:12 a.m., Employee #179 disclosed Resident #75 used to walk the halls independently and, within the past month, her mobility status changed and she was now using a reclining chair for locomotion around the unit. Employee #179, when asked to review the resident's plan of care, acknowledged the resident no longer ambulated the halls independently and she now used a wheelchair due to weakness. Employee #179 also disclosed that Resident #75 was currently being transferred by a manual lift, and this information was on the nursing assistant assignment sheets but not in the resident's current plan of care. .",2014-12-01
10853,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,312,D,0,1,ZHEQ11,". Based on observation, medical record review, and confidential staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition. Observation of Resident #35 during two (2) separate meals found her seated in a wheelchair that was too low to the table to facilitate ease of self-feeding, and the resident did not receive assistance with her meal for two (2) of four (4) meals observed. Resident identifier: #35. Facility census: 95. Findings include: a) Resident #35 During the evening meal on 02/01/10 and the noon meal on 02/02/10, observation found Resident #35 seated in a wheelchair, which placed her 6 inches lower than the table and interfered with her ability to reach her meal effectively in order to eat. The resident was unassisted with her meal for fifteen (15) minutes on 02/01/10, and she was unassisted with her meal for twenty (20) minutes on 02/02/10. On 02/01/10, the resident became frustrated and backed her wheelchair away from the table. On 02/10/10 during the noon meal,observation found the resident being fed by staff while still seated in the low wheelchair. On 02/11/10 during the noon meal, observation found the resident seated in a dining room chair while a staff member sat beside her. The resident was able to access her meal and was able to consume most of the meal by herself. A confidential interview, on 02/11/10, revealed the staff member was worried about the resident, in that he/she feared the resident was declining in her ability to feed herself and was concerned the resident might fall off of the chair without staff being right beside her for the whole meal. During this confidential interview, the staff member reported the resident was not able to eat independently. Review of the resident's 01/06/10 quarterly assessment found the assessor had recorded the resident as able to eat independently with set up help only. Review of the resident's care plan, dated 10/14/09, found staff was to set up her meal tray and assist her as needed as needed. .",2014-12-01
10854,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,325,D,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to assure a resident, whose physician prescribed a nutritional supplement be provided between meals three (3) times daily to address weight loss, received the supplements as ordered. This was evident for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #60. Facility census: 95. Findings include: a) Resident #60 Review of the medical record revealed a physician's orders [REDACTED].@ (at) 10 a., 3 p, and 8 p snack."" Review of a physician's progress note, dated 12/18/09, revealed this resident was losing some weight at the time and had steadily done so since her arrival at the facility a few months prior. Her most recent weight, on 12/18/09, was 121#, which was down from 123.6# recorded for the previous month. The physician wrote, on 12/18/09, he wanted Resident #60 to receive Ensure three (3) times daily between meals for nutritional issues and weight loss. The clinical nutrition assessment, dated 08/24/09, stated this resident's ideal body weight range was between 120 and 150 pounds. Interview with a nurse (Employee #72), on 02/09/10 at approximately 1:00 p.m., revealed the consumption of nutritional supplements was not documented in the medication administration record; rather, it was recorded by the nursing assistants on each resident's daily care record kept at the nurse's station. Review of the February 2010 resident daily care record for Resident #60 revealed blank spaces for the supplement at 10:00 a.m. on each day from 02/01/10 through and including 02/08/10, for a total of seven (7) missed opportunities to record the consumption of Ensure. Interview with Employees #142 and #149, on 02/09/10 at 1:00 p.m., revealed they did not have records of the resident diets and nutritional supplements on their assignment sheets. They reported the nurse makes the health service workers' assignment sheets based on each resident's plan of care. They further related that the dietary department brings the snacks and supplements to the floor labeled with the residents' names and the times to be given, and the nursing assistants passed the snacks and recorded snack consumption on the resident daily care records. These findings were discussed with the administrator at approximately 9:30 a.m. on 02/10/10. She reported they were aware of the care plans needing to be more specific and the facility had been working on that issue and would continue to do so. .",2014-12-01
10855,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,329,D,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary drugs. One (1) of thirty-two (32) Stage II sampled residents did not receive non-pharmacological interventions (such as behavioral interventions) instead of (or in addition to) medications administered to control behaviors. An anti-anxiety medication was provided to the resident with no evidence that non-pharmacological interventions were attempted prior to its use. Resident identifier: #73. Facility census: 95. Findings include: a) Resident #73 The medical record of Resident #73, when reviewed on 02/09/10, disclosed a nurse's note, dated 02/04/10 at 21:09 (9:09 p.m.), which recorded, ""Resident yelling, rhythmic repeating of words / sayings, and dumped water over her roommates (sic) items which were on the dresser. [MEDICATION NAME] 0.5 mg given at 6p (6:00 p.m.), res.(resident) continued the above behaviors."" This documentation provided no evidence staff attempted non-pharmacological interventions prior to the administration of the anti-anxiety medication [MEDICATION NAME]. An additional nurse's note, dated on 02/08/10 at 21:33 (9:33 p.m.), stated, ""Notified by Health Service Worker that res. was extremely agitated. When this nurse entered res. room at 3p (3:00 p.m.) res. was sitting in recliner and was loudly repeating her words, slapping the side of her chair and kicking her foot. [MEDICATION NAME] 0.5 mg given at that time. Res. had supper in B1 DR (dining room). Res. was given another [MEDICATION NAME] 0.5 mg at 7:15 p.m., as the above behavior continued."" Again, the record contained no evidence to reflect staff had attempted non-pharmacological interventions prior to the administration of the medication. A registered nurse (RN - Employee #136), when questioned related to the lack of non-pharmacologic interventions prior to the administration of an anti-anxiety medication, provided a document with the heading ""nonpharm (nonpharmacologic) man (manifestation) of disruptive/aggre (aggressive) event"". The RN explained that this document, and the steps noted on it, should be completed by the nurse prior to the administration of any behavior modification medication. The RN further confirmed no evidence was available to reflect this document, or the steps described on it, had been completed prior to the medication administration on these occasions for this resident. .",2014-12-01
10856,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,279,D,0,1,ZHEQ11,". Based on record review, staff interview, and policy review, the facility failed to develop and communicate to direct care staff a care plan that fully addressed the specific care needs of a resident with a blood-borne pathogen. This was evident for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #11. Facility census: 95. Findings include: a) Resident #11 Medical record review found Resident #11 had a blood-borne pathogen. Review of the care plan for this resident found problems and approaches related to this diagnosis. However, review of the nursing assistants' assignment sheets made no mention of any special precautions in potential care areas. During interview with the infection control nurse (Employee #130) on 02/10/10 at 9:30 a.m., she produced the infection control policies and procedures manual she used and agreed the policies and procedures in the manual needed to revised to enable nursing staff to know step-by-step how to handle various types of infection control measures, such as with this blood-borne pathogen. During interview with the administrator on 02/10/10 shortly after 9:30 a.m., she acknowledged the current policy and procedure manual did not give concrete instructions for nursing staff to follow and had nothing specific to guide nursing regarding care and precautions for a resident with this type of blood-borne pathogen other than the standard precautions used for all residents. During interview with a direct care nurse (Employee #136) on 02/11/10 at 12:30 p.m., she stated guidelines to follow for this type of situation for the blood-borne pathogen were located in a big white book, and she did not know why they were not in the infection control policy and procedure manual. Interview with nursing assistants (Employees #142 and #149), on 02/11/10 at 1:05 p.m., revealed they are aware of the resident having a blood-borne pathogen and of what precautions to take, even though this information not written in the assignment book or in the care plan. The nursing assistants said everyone who worked on that hall should already know of the blood-borne pathogen and, for example, and should already be aware of certain precautions, such as not using a regular razor on him when shaving. They acknowledged that using an electric razor was not written on the assignment sheet. Review of the care plan revealed he was to use an electric razor to shave with, but this was not conveyed on the health service workers' assignment sheets. Review of the care plan revealed staff was to use universal precautions when rendering care, but this was not conveyed on the health service workers' assignment sheets. Review of the care plan revealed he was to sit at a table by himself to eat meals due to his spitting food and sneezing on peers when sitting with them, but this was not conveyed on the health service workers' assignment sheets. .",2014-12-01
10857,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,323,D,0,1,ZHEQ11,". Based on observation and staff interview, the facility failed provide an environment as free of accident hazards as is possible, as evidenced by leaving one (1) medication cart unlocked and unattended in the 200A hall. This had the potential to affect all ambulatory residents on the 200A Hall. Facility census: 95. Findings include: a) Observation on the 200A hall, on 02/09/10 at 12:50 p.m., found a medication cart unlocked and unattended, with the lower right hand drawer left open as the nurse (Employee #72) entered into Room 211 and closed the door behind her. One (1) resident, who was wandering in the hallway, passed the medication cart twice before the nurse returned to the medication cart a couple of minutes later. The nurse was informed by this surveyor of the wandering resident who passed the unlocked medication cart twice while it was unattended in the hallway. No further information was obtained. This deficient practice was reported to the administrator during the exit conference on 02/11/10. .",2014-12-01
10858,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,278,D,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to accurately encode assessments for two (2) of thirty-two (32) Stage II sampled residents. Resident identifiers: #35 and #77. Facility census: 95. Findings include: a) Resident #35 On 02/01/10 at 5:18 p.m., observation found Resident#35 in the B1 dining room seated in a low scoop chair with a Velcro lap belt attached. The resident was seated at a table, and the belt was not released during the meal. On 02/09/10 during the noon meal observation, a nursing assistant (Employee #10) fed Resident #35, and the resident's Velcro seat belt remained attached during lunch. During the noon meal on 02/11/10, observation found the resident sitting in a regular dining room chair. A confidential staff interview, at about 12:30 p.m. on 02/11/10, found the resident was at risk for falling while sitting in a regular dining room chair for meals, and she could not be left alone while in the chair. The employee was concerned about the resident's safety. Record review found a physician's orders [REDACTED]. On 10/18/09, the physician ordered staff to apply a self-release Velcro seat belt when the resident was in the scoot chair to remind her to not to get up without assistance. On 11/03/09, the physician ordered the application of a chair alarm while the resident was in the scoot chair to alert staff to the need for assistance. On a fall risk assessment dated [DATE], the assessor gave Resident #35 a score of ""30"", with a score of ""10"" or more indicating the resident was at ""high risk"" for falls. An addendum stated, ""Due to recent falls out of her chair will suggest a Velcro seat belt be used..."" On a fall risk assessment dated [DATE], the assessor gave the resident a score ""29"" (high risk); an addendum stated, ""Resident is currently in a scoot chair with a Velcro seat belt. Requires staff assistance with all transfers."" A nursing note, dated 10/18/09 at 12:07 p.m., stated, ""Resident's roommate yell (sic) help. Staff entered room to find (Resident #35) on the floor. Roommate was the first to speak stated, 'I did not turn the alarm off.' No noted injury at this time. Hipsters were in place. ROM WNL (range of motion within normal limits). New order written for a Scoot chair with Velcro seat belt. 15 minutes check cont."" A nursing note, dated 11/03/09 at 14:32 (2:32 p.m.) stated, ""...found on floor due to releasing her seatbelt while in scoot chair. Since she can release the Velcro seatbelt it doesn't restrain her movements, only slow her down a little. A chair alarm will be added to Scoot chair to alert staff for assistance. Hipsters in place at which prevent injuries."" Review of the resident's care plan revealed a problem statement dated 05/18/06, which identified the resident as having the potential to fall. Interventions included staff was to encourage the resident to ask for assistance, hipsters at all times, and check every fifteen (15) minutes. On 10/19/09, staff added the intervention: ""Scoot chair with seat belt. D/C (discontinue) Velcro seat belt while in wheelchair."" On 11/03/09, staff added: ""Chair alarm while in scoot chair to alert staff for assistance. Provide assistance as needed."" Review of the resident's abbreviated quarterly assessment, with an assessment reference date of 01/06/10, found the resident had short and long term memory problems, had moderately impaired cognitive skills for daily decision making, sometimes understood others and sometimes could make herself understood, required extensive assistance to walk in her room or in the corridor, and had fallen within the last thirty (30) days. The assessment did not reflect the use of any devices / restraints. b) Resident #77 Review of the medical record, on the afternoon of 02/09/10, disclosed a quarterly assessment dated [DATE]. This assessment identified, in Section G4 (functional limitation in range of motion) the resident had limitations in range of motion on both of his arms and legs. Another quarterly assessment, dated 01/21/10, noted in Section G4 a decline in his range of motion with partial loss of voluntary movements of both his arms and legs. Review of the resident's current care plan found no mention of interventions to prevent further decline in the resident's range of motion. On 02/11/10 at 2:45 p.m., the assessment coordinator (Employee #105) was informed of these assessment findings and the absence of care planning interventions to prevent further decline. Employee #105 reviewed the medical record and, approximately twenty (20) minutes later, identified the assessment dated [DATE] was incorrect; the resident had not experienced a decline in range of motion. .",2014-12-01
10859,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-08-25,246,D,1,0,RIOG11,". Based on a random opportunity for observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs and preferences regarding one (1) resident's environment when he chose to eat his lunch in his room. Staff behaviors were not directed toward assisting the resident in maintaining independent functioning or dignity when they failed to turn on the lights in the resident's room while he ate his noon meal. Resident identifier: #4. Facility census: 45. Findings include: a) Resident #4 A random observation, on 08/25/11 at 12:15 p.m., found this resident was eating lunch in his room. It was a rainy and dull day, and the room appeared dim. Further observation revealed the light had not been turned on for the resident. Additionally, the curtain between the beds in the room was pulled, blocking any potential light from the window on the other side of the room. Upon inquiry, the resident stated he would like the light turned on so he could see what he was eating. At 12:25 p.m., an interview was conducted with a lead nursing assistant (Employee #30) and the minimum data set coordinator (Employee #4). Each of these employees confirmed staff should have turned on the resident's light when his meal was served. .",2014-12-01
10860,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-08-25,225,E,1,0,RIOG11,". Based on record review and staff interview, the facility failed to evaluate and /or investigate eighteen (18) unwitnessed and unexplained bruises affecting twelve (12) facility residents. Thirty-six (36) incidents of unknown bruising were reviewed for the period of 07/01/11 through 08/19/11. There was no evidence eighteen (18) of the thirty-six (36) unwitnessed incidents of bruising, affecting twelve (12) residents, were investigated to rule out potential abuse or neglect. Resident identifiers: #3, #47, #6, #15, #48, #20, #21, #36, #32, #35, #29, and #41. Facility census: 43. Findings include: a) Resident #21 An Event Management Report (EMR) for Resident #21, dated 07/20/11, noted two (2) bruises on the left forearm. A second EMR for Resident #21, dated 07/27/11, noted three (3) bruises on the right forearm measuring 3 cm x 2 cm, 10 cm x 3 cm, 8 cm x 4 cm respectively. A third EMR for Resident #21, dated 08/15/11, noted a discoloration to the right forearm measuring 11 cm x 4 cm. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruises for any of these bruises of unknown origin to rule out potential abuse or neglect for this resident. - b) Resident #20 An EMR for Resident #20, dated 07/11/11, noted a bruise on right upper arm. The cause noted on the EMR was: ""? Hoyer lift."" There was no evidence the facility evaluated and/or investigated whether or not the use of a Hoyer lift actually caused this bruise of unknown origin. - c) Resident #41 An EMR for Resident #41, dated 08/01/11, noted a bruise on the right side of the resident's body and a second on the resident's right upper arm. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruises of unknown origin to rule out potential abuse or neglect for this resident. - d) Resident #47 An EMR for Resident #47, dated 07/04/11, noted four (4) bruises on the left arm, one (1) bruise on the left knee, and one (1) bruise on the inner aspect of the left leg. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruises of unknown origin to rule out potential abuse or neglect for this resident. - e) Resident #48 An EMR for Resident #48, dated 07/10/11, noted two (2) bruises on the left elbow and one (1) bruise to the right thigh. There was no evidence the facility evaluated and/or investigated possible cause(s) of these bruises of unknown to rule out potential abuse or neglect for this resident. - f) Resident #32 An EMR for Resident #32, dated 07/24/11, noted one (1) bruise on the right upper arm measuring 3.4 cm x 7.8 cm. A cause of ""unknown"" was noted. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruise of unknown origin to rule out potential abuse or neglect for this resident. - g) Resident #3 An EMR for Resident #3, dated 07/04/11, noted bruises of unknown origin on both hands and forearms. There was no evidence the facility evaluated and/or investigated possible cause(s) of these bruises to rule out potential abuse or neglect for this resident. - h) Resident #6 An EMR for Resident #6, dated 07/05/11, noted two (2) bruises on the back of the right hand. There was no evidence the facility evaluated and/or investigated possible cause(s) of these bruises of unknown origin to rule out potential abuse or neglect for this resident. - i) Resident #15 An EMR for Resident #15, dated 07/06/11, noted a bruise on the left forearm. There was no evidence the facility evaluated and/or investigated possible cause(s) of this bruise of unknown origin to rule out potential abuse or neglect for this resident. - j) Resident #36 An EMR for Resident #36, dated 08/17/11 at 5:20 a.m., noted the discovery of two (2) areas of ""discoloration"". One (1) area of discoloration was located on the right forearm and one (1) on the right hand. There was no evidence the facility evaluated and/or investigated possible cause(s) of these bruises of unknown origin to rule out potential abuse or neglect for this resident. - k) Resident #35 An EMR for Resident #35, dated 07/27/11, noted a bruise on the left elbow. There was no evidence the facility evaluated and/or investigated possible cause(s) of this bruise of unknown origin to rule out potential abuse or neglect for this resident. - l) Resident #29 An EMR for Resident #29, dated 08/17/11, noted an area of discoloration on the right hand. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruise to rule out potential abuse or neglect for this resident. - m) The assistant director of nursing (Employee #73), who was responsible for addressing accidents and incidents in the facility, was interviewed on 08/24/11 at 10:30 a.m. She confirmed the facility had a problem with the large number of incidents resulting in bruises of unknown origin. She confirmed the facility had not investigated or evaluated potential cause(s) of these bruises in order to rule out potential abuse or neglect. .",2014-12-01
10861,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-08-25,312,D,1,0,RIOG11,". Based on observation, resident interview, staff interview and record review, the facility failed to provide the necessary services for one (1) of sixteen (16) sample residents whose grooming and personal hygiene needs had increased. The resident had been independent in grooming and personal hygiene, but these abilities had declined. The facility failed to assess and care plan the resident's current activity of daily living (ADL) needs; therefore, the resident did not consistently receive the grooming and personal hygiene services she required. Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 Observation, on 08/23/11 at 9:25 a.m., found this resident wearing a tee-shirt top and blue sweat pants. The resident's hair was clean and combed around her face, but it was sticking up in the back. The resident was later observed in the dining room, at 11:15 a.m. this same day. Her hair was still flat and sticking up in the back. An observation made in the resident's room, at 11:25 a.m. on 08/24/11, revealed the resident had a strong smell of urine. Additionally, her hair was greasy and uncombed. The resident was in bed wearing the same blue sweat pants as she had worn on the morning of 08/23/11. - On 08/24/11, the admission and two (2) quarterly MDSs were reviewed. The admission MDS had an assessment reference date of 02/06/11, and the quarterly MDSs were completed in April 2011 and July 2011. Under Section G (Functional Status) of these MDSs, Resident #24 was coded as requiring no help or staff oversight at anytime, and she required set-up help only with bathing, personal hygiene (which includes combing hair), and toilet use. Under Section H, both urinary incontinence and bowel incontinence were coded continent. - An observation, on 08/25/11 at 8:45 a.m., revealed the resident was in bed wearing the same blue sweat pants she had worn on the morning of 08/23/11. The front of the blue sweat pants had multiple food crumbs all over them. The resident had a strong urine odor, and her hair was greasy and uncombed. When the resident was asked where she took her bath or showered, the resident pointed to the bathroom door in her room. Upon inspection, the bathroom contained a toilet and sink. There was no shower or tub in this room. When asked if it was difficult to bathe in this room, the resident did not reply but shrugged her shoulders. According to the resident, she washed her hair by wrapping cloths around her hand and rubbing them through her hair. When asked if this was okay, the resident shrugged her shoulders. - On 08/25/11 at 8:55 a.m., an interview was conducted with two (2) nursing assistants (NAs). These NAs (Employees #30 and #46) stated they were familiar with Resident #25. When asked when the resident received a shower, Employee #30 stated the resident did her own bath in her room and, sometimes, another NA (Employee #46) could get the resident to take a shower. Employee #46 stated, ""Sometimes I can get her to go to the shower."" When asked about the strong urine smell, Employee #30 stated, ""I wash her bottom and back if she will let me."" Employee #30 further stated, ""She is not able to clean herself well and still smells of urine even though the resident said she had taken a bath."" Both Employees #30 and #46 agreed the resident was no longer able to independently do her own bath and hair. - On 08/25/11 at 9:30 a.m., an additional interview was conducted with Employees #30 and #46. When asked how they knew what care and/or assistance Resident #25 required, they both said this information would be found on the Info Sheet (Nurse Aide's Information Sheet or 'IS') and the ADL (activities of daily living) worksheet. The IS was dated as revised 06/14/11. The ADL worksheet was marked August 2011. In the grooming section of the IS, check marks were noted in hair, comb, self, and supervise. In the area of personal hygiene on the ADL worksheet was found the following notation: ""requires set up / supervision; brush teeth; comb hair, and perineum care."" The bowel and bladder section of the IS noted the resident was continent of both bowel and bladder and used the bathroom. The ADL worksheet under the toilet use section contained the following notation: ""Independent with toileting. Continent bladder. Incontinent bowels. Wears incontinent briefs. Incontinent check and change Q (every) two (2) hours. Offer Toileting when awakens, before/after meals at HS (hour of sleep) and when asks."" Under the comment section of the IS was a written note by an unknown author which stated, ""Supervise care. Does most of it herself."" After reviewing this information with the Employees #30 and #46 on 08/25/11 at approximately 9:30 a.m., both employees agreed there was conflicting information on the forms and the information did not reflect either the current needs of the resident or the care the resident was actually receiving. - On 08/25/11 at 10:30 a.m., an interview was held with the MDS coordinator (Employee #4) and Employee #30. Employee #30 explained the resident was not able to comb her hair or take a bath independently and stated, ""I wash her bottom and back if she will let me."" A review of the MDS, care plan, and NA documentation forms was conducted with the MDS coordinator at that time. The MDS coordinator explained the information on the NA documentation forms came from the care plan. The MDS coordinator said she was not aware of these changes in the resident's ADL self-performance status. At that time, Employee #4 agreed the information contained in Resident #25's care plan and NA forms did not accurately reflect the current level of staff assistance needed by Resident #25 for these activities of daily living.",2014-12-01
10862,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-08-25,274,D,1,0,RIOG11,". Based on observation, staff interview and record review, the facility failed to accurately assess the care needs for one (1) of sixteen (16) sample residents. The resident had experienced a significant decline in the self-performance of bathing and personal grooming, and this decline was not identified in the current minimum data set (MDS). Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 Observation, on 08/23/11 at 9:25 a.m., found this resident wearing a tee-shirt top and blue sweat pants. The resident's hair was clean and combed around her face, but it was sticking up in the back. The resident was later observed in the dining room, at 11:15 a.m. this same day. Her hair was still flat and sticking up in the back. An observation made in the resident's room, at 11:25 a.m. on 08/24/11, revealed the resident had a strong smell of urine. Additionally, her hair was greasy and uncombed. The resident was in bed wearing the same blue sweat pants as she had worn on the morning of 08/23/11. - On 08/24/11, the admission and two (2) quarterly MDSs were reviewed. The admission MDS had an assessment reference date of 02/06/11, and the quarterly MDSs were completed in April 2011 and July 2011. Under Section G (Functional Status) of these MDSs, Resident #24 was coded as requiring no help or staff oversight at anytime, and she required set-up help only with bathing, personal hygiene (which includes combing hair), and toilet use. Under Section H, both urinary incontinence and bowel incontinence were coded continent. - An observation, on 08/25/11 at 8:45 a.m., revealed the resident was in bed wearing the same blue sweat pants she had worn on the morning of 08/23/11. The front of the blue sweat pants had multiple food crumbs all over them. The resident had a strong urine odor, and her hair was greasy and uncombed. When the resident was asked where she took her bath or showered, the resident pointed to the bathroom door in her room. Upon inspection, the bathroom contained a toilet and sink. There was no shower or tub in this room. When asked if it was difficult to bathe in this room, the resident did not reply but shrugged her shoulders. According to the resident, she washed her hair by wrapping cloths around her hand and rubbing them through her hair. When asked if this was okay, the resident shrugged her shoulders. - On 08/25/11 at 8:55 a.m., an interview was conducted with two (2) nursing assistants (NAs). These NAs (Employees #30 and #46) stated they were familiar with Resident #25. When asked when the resident received a shower, Employee #30 stated the resident did her own bath in her room and, sometimes, another NA (Employee #46) could get the resident to take a shower. Employee #46 stated, ""Sometimes I can get her to go to the shower."" When asked about the strong urine smell, Employee #30 stated, ""I wash her bottom and back if she will let me."" Employee #30 further stated, ""She is not able to clean herself well and still smells of urine even though the resident said she had taken a bath."" Both Employees #30 and #46 agreed the resident was no longer able to independently do her own bath and hair. - On 08/25/11 at 10:30 a.m., an interview was held with the MDS coordinator (Employee #4) and Employee #30. Employee #30 explained the resident was not able to comb her hair or take a bath independently and stated, ""I wash her bottom and back if she will let me."" A review of the MDS was conducted at this time with the MDS coordinator. The MDS coordinator said she was not aware of these changes in the resident's ADL self-performance status. At that time, Employee #4 agreed the information contained in the MDS did not accurately reflect the current ADL status of Resident #25. .",2014-12-01
10863,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-08-25,280,D,1,0,RIOG11,". Based on staff interview and record review, the facility failed to revise the care plan for one (1) of sixteen (16) sample residents when the resident experienced an increased need for staff assistance with bathing and grooming. Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 A review of the care plan for Resident #25 was conducted in the afternoon of 08/24/11. The care plan, completed on 07/20/11, stated the resident ""requires setup / supervision with dressing, personal hygiene, and bathing."" - On 08/25/11 at 8:55 a.m., an interview was conducted with two (2) nursing assistants (NAs). These NAs (Employees #30 and #46) stated they were familiar with Resident #25. When asked when the resident received a shower, Employee #30 stated the resident did her own bath in her room and, sometimes, another NA (Employee #46) could get the resident to take a shower. Employee #46 stated, ""Sometimes I can get her to go to the shower."" When asked about the strong urine smell, Employee #30 stated, ""I wash her bottom and back if she will let me."" Employee #30 further stated, ""She is not able to clean herself well and still smells of urine even though the resident said she had taken a bath."" Both Employees #30 and #46 agreed the resident was no longer able to independently do her own bath and hair - On 08/25/11 at 10:30 a.m., an interview was held with the MDS coordinator (Employee #4) and Employee #30. Employee #30 explained the resident was not able to comb her hair or take a bath independently and stated, ""I wash her bottom and back if she will let me."" A review of the MDS, care plan, and NA documentation forms was conducted with the MDS coordinator at that time. The MDS coordinator explained the information on the NA documentation forms came from the care plan. The MDS coordinator said she was not aware of these changes in the resident's ADL self-performance status. At that time, Employee #4 agreed the information contained in Resident #25's care plan and NA forms did not accurately reflect the current level of staff assistance needed by Resident #25 for these activities of daily living. .",2014-12-01
10563,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,279,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, the facility failed to develop care plans to address physician orders [REDACTED].#10, #46, and #65). Facility census: 114. Findings include: a) Resident #10 Review of the resident's medical record found a Physician order [REDACTED]. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted ""comfort measures"" for this resident. b) Resident #46 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 09/04/07. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted ""comfort measures"" for this resident. c) Resident #65 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 04/30/09. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted ""comfort measures"" for this resident. d) Review of the POS [REDACTED]. --- Part II -- Based on observation, staff interview, and record review, the facility failed to include in the care plan the use of physician-ordered Hipsters to address injuries with falls, nor did the care plan address the fact that the resident would frequently remove this safety device. This was evident for one (1) of twenty (20) sampled residents. Resident identifier: #49. Facility census: 114. Findings include: a) Resident #49 Review of the medical record revealed this resident entered the facility within the past year after sustaining a broken hip. Further review revealed the September 2009 monthly recapitulation of physician's orders [REDACTED]. Check every shift."" Observation of Resident #49, on 10/20/09 at 4:15 p.m., revealed he was exiting his bathroom and standing at his bathroom door unattended. This surveyor immediately notified the closest nurse, who assisted him to dress and return to bed. There were no alarms sounding. After he was dressed and back in his bed, the nurse (Employee #150) stated, when asked, that he had no Hipsters in his room to put on, nor were there any Hipsters in the bathroom from where he had just been. She said he sometimes takes them off and puts them under the mattress or in the trash can. She said she looked under his mattress and in the bathroom and did not see them and would get a new pair to put on him. When the above findings were reported to the assistant director of nursing (ADON) on 10/20/09 at 4:35 p.m., the ADON related Resident #49 was known to take off his TED stockings and Hipsters. Interview, on 10/21/09 at 10:30 a.m., with the DON and Employee #150 revealed they were aware he would take off his Hipsters. Review of Resident #49's care plan revealed he had a focus for being at risk for falls due to multiple issues, one (1) of which was ""removal of preventive devices and non-skid footwear related to Dementia"". Interventions included ensuring sensor pad alarm was in place when in wheelchair or bed and monitoring for proper functioning and placement; having the call bell in reach; and monitoring for safety issues and correct. His care plan did not include the physician's orders [REDACTED]. .",2015-01-01
10564,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,225,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on incident / accident report review and staff interview, the facility failed to immediately report and/or thoroughly investigate four (4) injuries of unknown source affecting two (2) of twenty (20) sampled residents. Resident identifiers: #2 and #15. Facility census: 114. Findings include: a) Resident #2 1. Review of an incident report, dated 06/11/09 at 9:00 a.m., found the resident had a bruise on the left breast measuring 6 cm x 7 cm., a bruise to the left side of the neck measuring 4 inches x 5 inches, and a bruise under the left breast measuring 4 x 11 inches. The description of the incident also included, ""... Bruises are consistent with resident taking ASA (aspirin)."" There was no documentation discussing how the use of aspirin would result in extensive bruising of the neck and breast, which are not areas of the body generally vulnerable to trauma. 2. Review of an incident report, dated 06/15/09 at 11:00 a.m., found the resident had six (6) new bruises - a bruise on right upper back measuring 4 x 4 (no units of measurement provided), a bruise on the mid back measuring 3 x 7 (no units of measurement provided), a bruise behind the left knee measuring 5 cm x 1 cm, a bruise to coccyx measuring 4 cm x 5 cm. Also recorded was: ""Resident takes ASA therapy. Also she ambulates by herself & bumps into objects at times while ambulating."" There was no documentation discussing how the use of aspirin and/or bumping into objects while self-ambulating would result in extensive bruising of the back / coccyx and bruising behind the knee, which are not areas of the body generally vulnerable to trauma. 3. During a review of these incident reports with the director of nursing (DON - Employee #121) on the mid-morning of 10/22/09, the DON related she believed the resident bumped herself while ambulating and this was the cause of the bruising noted on the incident reports of 06/11/09 and 06/15/09. She stated that, after the resident was moved to a different room, the bruising stopped. She did not believe further investigation was needed, and the injuries of unknown origin were not reported to the State surveying agency. b) Resident #15 Review of an incident report, dated 08/21/09, revealed Resident #15 sustained an injury to her right calf measuring 9 cm x 2 cm x 3 cm with a moderate amount of bleeding. Documentation on the incident stated she was medicated with Tylenol for pain and sent to the emergency room for treatment. There was no evidence of an investigative report in the record, nor was there evidence of a report of this injury of unknown source having been sent to the State surveying agency. Interview with the DON, on 10/21/09 at approximately 3:00 p.m., revealed that staff could find no blood anywhere in the building nor on the wheelchair; she was wearing long pants at the time the injury was discovered, and the pant leg had no cut or tear. She said they concluded the laceration could only have been caused by her leg rubbing against a sharp place on the wheelchair and, subsequently, they wrapped the sharp place with a cloth to pad it, noting they could find no blood on the wheelchair. The 08/21/09 incident report stated that a medical device was not involved in the injury; the DON stated this was written in error. She also explained that, due to the resident's [MEDICAL CONDITION], she had decreased sensation to the extremities and would not have been able, initially, to feel the pain from rubbing the area repeatedly while propelling in the wheelchair. Interview with Resident #15, on 10/22/09 at 10:30 a.m., revealed she was unable to remember or discuss the injury to the right calf. During interview with the assistant director of nursing (ADON - Employee #120) on 10/22/09 at 10:40 a.m., she stated Resident #15 would not be able to tell me how she cut her leg, nor was she able tell staff what happened at the time of the injury. Review of nurses' notes, dated 08/21/09 at 6:00 p.m., revealed a nursing assistant reported Resident #15 complained of leg pain; staff at that time found the laceration to the right calf measuring 9 cm x 2 cm with a depth of 3 cm and a moderate amount of bleeding. Review of the medical record revealed [DIAGNOSES REDACTED]. .",2015-01-01
10565,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,329,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen were free of unnecessary drugs for two (2) of twenty (20) sampled residents. Resident #10 was ordered [MEDICATION NAME] 25 mg on 08/21/08 for depression; the drug was not identified for a gradual dose reduction attempt after twelve (12) months, and there were no documented indications for continued use at the present dose. Resident's #65's physician increased the resident's daily dosages of [MEDICATION NAME] and [MEDICATION NAME] with no evidence found in the resident's behavior records or nursing notes to indicate the resident's target behaviors had increased in frequency or duration necessitating an increase in these medications. Facility census: 114. Findings include: a) Resident #10 Record review found an order for [REDACTED]. A review of the pharmacist's monthly drug regimen reviews for the resident also found no recommendation that a gradual dosage reduction should be attempted for the resident after twelve (12) months of use. b) Resident #65 Record review found the attending physician, on 10/19/09, increased the resident's daily dose of [MEDICATION NAME] from 0.25 mg every morning and 0.5 mg at bedtime (with an additional order for [MEDICATION NAME] 0.25 mg twice daily as needed) to [MEDICATION NAME] 0.5 mg twice daily. At the same time, the physician increased the daily dose of [MEDICATION NAME] from 0.5 mg twice daily to 1 mg twice daily. A review of the psychiatrist's progress notes, dated 10/19/09, found the resident ""continues to (illegible) agitation, yelling in appropriately. Cannot be directed, too confused. At present on [MEDICATION NAME] .5 mg bid (twice daily) not over sedated. Recommendations: 1. D.C. (discontinue) [MEDICATION NAME] .5 bid. 2. Give [MEDICATION NAME] 1 mg bid. 3. [MEDICATION NAME] 0.5 mg bid."" The resident's [MEDICATION NAME] and [MEDICATION NAME] were increased accordingly, per 10/19/09 physician's orders [REDACTED]. Review of the behavior tracking tool and nursing notes found no documentation to reflect the resident exhibited the target behaviors ""yelling out for no reason"" or ""cursing"" from 09/24/09 through 10/19/09. The only behavioral episode recorded during this period was refusal of milk of magnesia on 10/12/09; refusal of medications was not identified as a target behavior requiring the administration of psychoactive medications. An interview with the assistant director of nursing, on 10/21/09 at 11:25 a.m., found the consulting psychiatrist received his information from information she had gathered, and she was unable to find any additional information that would indicate an increase in psychoactive medications was medically necessary.",2015-01-01
10566,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,492,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to provide information regarding hospice-palliative care to residents with orders for comfort measures, as required by Chapter 16, Article 5C of the West Virginia State Code. This occurred for three (3) of twenty (20) sampled residents (#10, #46, and #65) Facility census: 114. Findings include: a) Resident #10 Review of the resident's medical record found a Physician order [REDACTED]. The form indicated the resident was not to be resuscitated and was to be provided ""comfort measures"". There was no evidence the resident's health care surrogate (HCS) had been provided information about hospice-palliative care. b) Resident #46 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 09/04/07. The form indicated the resident was not to be resuscitated and was to be provided ""comfort measures"". There was no evidence the resident's HCS had been provided information about hospice-palliative care. c) Resident #65 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 04/30/09. The form indicated the resident was not to be resuscitated and was to be provided ""comfort measures"". There was no evidence the HCS had been provided information about hospice-palliative care. d) West Virginia State Code (16-5C-20) states: ""Hospice palliative care required to be offered. ""(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]. If a nursing home resident is incapacitated, the facility shall also notify any person who has been given the authority of guardian, a medical power of attorney or health care surrogate over the resident, information stating that the resident has the option of receiving hospice palliative care. ""(b) The facility shall document that it has notified the resident, and any person who has been given a medical power of attorney or health care surrogate over the resident, information about the option of hospice palliative care and maintain the documentation so that the director may inspect the documentation, to verify the facility has complied with this section.' e) Review of the POS [REDACTED]. .",2015-01-01
10567,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,428,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure irregularities in each resident's medication regimen were identified and reported to the attending physician and director of nursing for action. Resident #10 was ordered Zoloft 25 mg on 8/21/08 for depression; the drug was not identified for a gradual dose reduction attempt after twelve (12) months of use, and there were no documented indications for continued use at the present dose. This affected one (1) of twenty (20) sampled residents. Facility census: 114. Findings include: a) Resident #10 Record review found an order for [REDACTED]. A review of the pharmacist's monthly drug regimen reviews for the resident also found no recommendation that a gradual dosage reduction should be attempted for the resident after twelve (12) months of use. An interview with the assistant director of nursing, on 10/21/09 at 11:25 a.m., failed to yield any additional evidence that the need for a gradual dosage reduction attempt was identified. .",2015-01-01
10568,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,203,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of discharge / transfer appeal rights form, given to one (1) of twenty (20) sampled residents (#2), the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the notice may led a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) Resident #2 Review of the uniform notification of discharge / transfer appeal rights form, provided by the facility for Resident #2 and dated 07/09/09, revealed the following: ""This is to inform you that you have the right to appeal the decision made by this facility to transfer discharge you to..."" This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, the local mental health center, Advocates for Developmentally Disabled and Mentally Ill, Legal Aid of West Virginia, and Office of Heath Facility Licensure and Certification. This notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may led a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."", not the ""Advocates for Developmentally Disabled and Mentally Ill"". .",2015-01-01
10569,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,154,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to fully inform one (1) of twenty (20) sampled residents, who had been determined by his physician to have the capacity to make his own healthcare decisions, of his rights as a resident, his healthcare status and the treatment interventions planned, and/or his discharge planning arrangements. Resident identifier: #62. Facility census: 114. Findings include: a) Resident #62 A review of the medical record revealed Resident #62 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His attending physician determined he lacked the capacity to make his own informed healthcare decisions on 04/13/09, and assigned his niece as his health care surrogate (HCS). The social services note, written by the social worker (SW - Employee #80) on 09/29/09, recorded the resident's niece came to the facility on this date and stated that, for health reasons, she could no longer serve as the resident's HCS. She was advised the facility would seek a HCS from WV DHHR. There was also evidence that a 30-day notice of discharge had been mailed to the HCS on or about 09/24/09, although she reported to the SW she had not received it. On 10/06/09, the resident's attending physician determined the resident now demonstrated the capacity to make his own informed healthcare decisions. All social services notes, progress notes, and nurses' notes after that date were reviewed, but there was no evidence that the resident had his care plan (especially his discharge plan) or his rights explained to him. During the general tour at 3:30 p.m. on 10/19/09, this resident approached the surveyor and asked if there was any rule about the sharing of the television in his room; he also asked the surveyor to find out why he had not been discharged yet. At 11:20 a.m. on 10/20/09, the resident was interviewed about his healthcare status. He said he was sick a few months ago but was well now and ready to go home. He could not relate to the surveyor any healthcare instructions and said that his niece took care of everything. During an interview with the social worker (Employee #80) at 9:45 a.m. on 10/21/09, she acknowledged the resident had not ""formally"" been included in any care discussions since he had been declared to have capacity and that the niece had formally rescinded her agreement to act as HCS for the resident. There was no evidence in the record that the resident had been informed of his rights, his code status, or that the facility has issued a 30-day notice of discharge. .",2015-01-01
10570,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,156,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to fully inform residents both orally and in writing when changes will occur in their bills and/or of their appeal right to request that a bill be submitted to Medicare for three (3) random reviewed residents, and failed to clearly denote in the resident's clinical record the advance directive formulated by the resident for one (1) of twenty-three (23) sampled residents. Resident identifiers: #100, #118, #49, and #116. Facility census: 114. Findings include: a) Residents #100, #118, and #49 A review of the ""Skilled Nursing Facility Determination"" letters on file at the facility for Residents #100 (two (2) letters on file) and #118 failed to provide evidence that the resident or the resident's legal representative was informed of the discontinuance of a skilled service prior to the service being stopped, as the signatures of the resident and/or the legal representative were not dated, and on the letter dated 08/27/09 for Resident #100, there was no date for the non-coverage of services. None of the letters reviewed show evidence of the resident's or legal representative's decision to request a bill to be submitted to the intermediary for a Medicare decision, as that area of the letter was blank. During an interview with the administrator at 10:20 a.m. on 10/22/09, she acknowledged the letters were not completed per facility policy and the intent of the form. b) Resident #116 Review of the closed record for Resident #116 revealed a Physician order [REDACTED]. In an interview with the social worker (Employee #80) at 4:00 p.m. on 10/21/09, she agreed there was a potential for error made by the inconsistencies. .",2015-01-01
10571,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,371,E,0,1,0YSZ11,"Based on observation and staff interview, the facility failed to ensure food products were properly stored in a sanitary manner in the central kitchen and the nutrition room on south side. In the central kitchen, observation found frozen vegetables stored on the freezer floor and open containers of cookies and beverage which were not properly labeled with the date opened. In the south side nutrition room, observation found open containers of milk products were not labeled with the date opened, other food products that were not labeled or dated, and drinking straws stored under the sink. These practices have the potential to affect all residents who would have access to these food products. Facility census: 114. Findings include: a) On 10/19/09 at 3:45 p.m., a tour of the kitchen was conducted with the cook (Employee #64). A box of frozen peas was observed on the floor of the freezer. The cook acknowledged the peas should not be stored on the freezer floor and removed the box. Further observation of the kitchen found two (2) bags of cookies to be opened. There was no label observed to indicate the date the cookies were initially opened. Employee #64 acknowledged the cookies were not labeled with a date and discarded them into the trash. b) During the general tour at 3:15 p.m. on 10/19/09, an observation of the refrigerator used to store food items for resident use located in the nutrition room on the south side revealed two (2) open containers of milk and two (2) open containers of half-and-half that were not labeled with the date they had been opened. There was also a covered container of what appeared to be vegetable soup with a label reading only ""my mom"" and no date and a second container of vegetables labeled with a name and room number but no date. Further observation of the nutrition room found open containers of packaged straws stored below a sink. The director of nurses, when informed of these observations, stated she would take care of it immediately. .",2015-01-01
10572,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,441,E,0,1,0YSZ11,"Based on observation and staff interview, the facility failed to ensure equipment intended for common use by residents was stored in a sanitary manner. During the general tour at 3:15 p.m. on 10/19/09, observation of the clean linen room on the south side revealed several fabric items lying on the floor including mechanical lift slings on various colors. This practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) During the general tour at 3:15 p.m. on 10/19/09, observation of the clean linen room on the south side revealed several fabric items lying on the floor including mechanical lift slings on various colors. This observation was relayed to the director of nursing at 3:50 p.m. on 10/19/09, who said she would take care of it immediately. A subsequent observation of this clean linen room, on the morning of 10/20/09, revealed the items were no longer on the floor. .",2015-01-01
10573,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,514,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the completeness and/or the accuracy of the medical records within acceptable professional standards for five (5) of twenty-three (23) sampled residents. Resident identifiers: #25, #115, #6, #38, and #9. Facility census: 114. Findings include: a) Resident #25 A review of the physician's orders [REDACTED].) The resident's Medication Administration Record [REDACTED]. This finding was pointed out to the assistant director of nursing at 9:50 a.m. on 10/20/09, who acknowledged the double orders and stated she would clarify the order. b) Resident #115 Resident #115's closed medical record, when reviewed on 10/21/09 at 3:00 p.m., disclosed a [AGE] year old female who was discharged from the facility on 09/24/09. The resident was receiving physical therapy post-operatively after a recent [MEDICAL CONDITION]. The admission physician orders, dated 07/10/09, reported the physician had ordered [MEDICATION NAME] 40 mg via subcutaneous injection every day for twelve (12) weeks. The July 2009 MAR indicated [REDACTED]. There was no evidence in the medical record the physician had discontinued the medication. The director of nurses (DON - Employee #121), when interviewed on 10/22/09 at 1:00 p.m., reported the primary physician gave a verbal order to discontinued the medication twenty-one (21) days post-operation. The DON acknowledged there was no evidence in the medical record to indicate the verbal order was received or signed by the physician. c) Resident #6 Resident #6's medical record, when reviewed on 10/20/09 at 11:30 a.m., revealed the October 2009 treatment sheet was incomplete for nurses' initials indicating treatments were completed as ordered by the physician. The physician orders [REDACTED]. The remedy skin repair cream treatment was not initialed for 10/10/09, 10/11/09, 10/12/09, 10/15/09, and 10/16/09 for 3:00 p.m.-11:00 p.m. shifts. The DON, when interviewed on 10/21/09 at 10:30 a.m., related the resident was not out of the facility on the above dates and stated, ""I could not say, if the treatment were or were not done."" Resident #6 was observed, on 10/20/09 at 10:00 a.m., with the treatment nurse (Employee #28). The resident's skin was intact without any breakdown or redness observed. d) Resident #38 Resident #38's medical record, when reviewed on 10/20/09 at 11:00 a.m., revealed the October 2009 treatment sheet was incomplete for nurses' initials indicating the treatment was completed as ordered by the physician. The physician ordered [MEDICATION NAME] cream to toes daily; this treatment was not initialed as having been completed on the following dates: 10/07/09, 10/10/09, 10/11/09, 10/12/09, 10/15/09, and 10/16/09. The DON, when interviewed on 10/21/09 at 10:30 a.m., related the resident was not out of the facility on the above dates and stated, ""I could not say, if the treatment were or were not done."" Resident #38 was observed, on 10/20/09 at 9:45 a.m., with Employee #28. The resident's toes were observed, and no redness or rash was noted. e) Resident #109 Resident #109's medical record, when reviewed on 10/21/09 at 11:30 a.m., revealed the September 2009 treatment sheet was incomplete for nurses' initials indicating treatments were completed as ordered by the physician. The physician ordered skin prep to both heels, elevate heels, and Sensicare cream every shift. The treatment sheet was not initialed for the following dates: 09/22/09, 09/23/09, 09/24/09, and 09/25/09 for the 3:00 p.m.-11:00 p.m. shift. Review of the medical record did not show any evidence the resident was out of the facility at the time the treatment were to be completed.",2015-01-01
10574,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,367,D,0,1,0YSZ11,"Based on observation, medical record review, resident interview, and staff interview, the facility failed to assure one (1) of twenty (20) sampled residents received a mechanically altered diet as prescribed by the physician. A resident, who was ordered a pureed diet, failed to receive the correct texture as ordered by the physician. Resident identifier: #6. Facility census: 114. Findings include: a) Resident #6 On 10/19/09 at 6:00 p.m., Resident #6 was observed in her room eating dinner. The entree was chili hot dogs. The resident was attempting to eat, yet consumed only a few small bites. The tray ticket read, ""Mechanically soft with ground meat."" The resident stated, ""It's hard to eat this."" The medical record, when reviewed on 10/19/09, disclosed the physician ordered a "" puree diet with enhanced foods"" on 10/07/09. The licensed practical nurse (LPN - Employee #77), when interviewed on 10/19/09 at 6:08 p.m., revealed the resident's current diet order was for ""puree consistency"" and the LPN stated, ""We got her a new tray."" The assistant dietary manager (Employee #24), when interviewed on 10/21/09 at 2:30 p.m., acknowledged the resident received the incorrect diet on 10/19/09. The assistant dietary manager revealed, ""The computer program froze up, and the dietary aide did not see the memo I put up."" .",2015-01-01
10575,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,328,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure specialized medical equipment was stored in a sanitary location. This was true for one (1) of twenty (20) sampled residents. A resident's nebulizer, nebulizer tubing, and oral suction machine were observed on the floor. Resident identifier: #38. Facility census: 114. Findings include: a) Resident #38 Observation, on 10/20/09 at 8:10 a.m., found Resident #38 in bed receiving oxygen at a rate of 2 liters per minute via nasal cannula. A nebulizer, nebulizer tubing, and oral suction machine were observed on the floor beside the bed. This alert resident, when interviewed, stated she received nebulizer treatments daily. Resident's #38's medical record, when reviewed on 10/19/09 at 4:00 p.m., revealed a [AGE] year old female with [MEDICAL CONDITION]. The resident's physician ordered suctioning as needed and [MEDICATION NAME] 600 mg via nebulizer treatments twice a day. The licensed practical nurse (LPN - Employee #137), when interviewed on 10/20/09 at 8:15 a.m., was shown the suction and nebulizer machines laying directly on the floor; she stated, ""They should not be there,"" and picked up the nebulizer and suction machines from the floor and removed them from the resident's room. .",2015-01-01
10576,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,323,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide care and services for one (1) of twenty (20) sampled residents with a history of falls with injuries, to reduce the likelihood of repeat fall-related injuries, by failing to ensure he wore Hipsters at all times when out of bed in accordance with physician orders. Resident identifier: #49. Facility census: 114. Findings include: a) Resident #49 Observation of Resident #49, on 10/20/09 at 4:15 p.m., revealed he was exiting his bathroom and standing at his bathroom door unattended. This surveyor immediately notified the closest nurse, who assisted him to dress and return to bed. There were no alarms sounding. After he was dressed and back in his bed, the nurse (Employee #150) stated, when asked, that he had no Hipsters in his room to put on, nor were there any Hipsters in the bathroom from where he had just been. She said he sometimes takes them off and puts them under the mattress or in the trash can. She said she looked under his mattress and in the bathroom and did not see them and would get a new pair to put on him. When the above findings were reported to the assistant director of nursing (ADON) on 10/20/09 at 4:35 p.m., the ADON stated Resident #49 will take off his TED stockings and Hipsters. Interview, on 10/21/09 at 10:30 a.m., with the DON and Employee #150 revealed they were aware he would take off his Hipsters. Review of the medical record revealed this resident entered the facility within the past year after sustaining a broken hip. Further review revealed the September 2009 monthly recapitulation of physician's orders [REDACTED]. Remove for bathing. Check every shift."" Review of nurses' notes, dated 09/15/09 at 2:30 p.m., revealed the nursing assistant reported Resident #49 stated he fell ; the resident was standing by the bed with full range of motion. The note did not state whether or not he was wearing Hipsters at this time. The following day, on 09/16/09 at 10:00 a.m., a nurse's note recorded the resident complained of discomfort to the right knee and hip when bearing weight; the physician was notified and awaiting response which arrived three (3) hours later. Mobile x-ray arrived at 5:00 p.m. with results, at 9:00 p.m., indicating a fracture of his good hip. Subsequently, he was transported to the hospital for surgical repair of the fractured hip. Further review of September 2009 nurses' notes revealed the Hipsters were not mentioned in any note that month prior to his fall and fracture. There was only a checklist system on the treatment record recording a check of the Hipsters once every shift. Review of Resident #49's care plan revealed he had a focus for being at risk for falls due to multiple issues, one (1) of which was ""removal of preventive devices and non-skid footwear related to Dementia"". Interventions included ensuring sensor pad alarm was in place when in wheelchair or bed and monitoring for proper functioning and placement; having the call bell in reach; and monitoring for safety issues and correct. His care plan did not include the physician's orders [REDACTED]. (See also citation at F279.) .",2015-01-01
10577,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,314,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, treatment record review, and staff interview, the facility failed to care and services to promote the healing of existing pressure sores as directed by the physician's orders [REDACTED]. Resident identifier: #49. Facility census: 114. Findings include: a) Resident #49 Review of October 2009 monthly recapitulation of physician's orders [REDACTED]. Medical record review revealed Resident #49 was admitted to the facility several months ago following a [MEDICAL CONDITION] repair after a fall at home. Medical record review further revealed that he had healing Stage III pressure ulcers to his heels. Review of Resident #49's care plan revealed an intervention for ""Posey gel boots bilaterally as ordered"" related to being at risk for alteration in skin integrity due to the presence of pressure areas on admission. On Tuesday, 10/20/09 at 4:30 p.m., the nurse (Employee #150) removed Resident #49's socks to inspect the status of the pressure ulcers on his heels. He was wearing a pair of mid-calf white socks with a pair of blue non-skid socks over them. He was not wearing Posey gel boots. She returned and said he was supposed to wear the Posey gel boots while in bed. These findings were reported to the director of nursing (DON) at 5:00 p.m. on 10/20/09. .",2015-01-01
10578,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-09-20,164,D,1,0,KU2H11,". Based on observation and staff interview, the facility did not ensure the confidentiality of medical records when a nurse left a binder of residents' medication administration records (MARs) on unattended and open to view in the hallway during a medication pass. Facility census: 119. Findings include: a) A random observation, on 09/19/11 at 7:30 p.m., found an unattended medication cart on top of which was a binder of MARs open to view. The MAR indicated [REDACTED]. At that time, a visitor was walking in the hallway and would have been able to view the contents of that resident's MAR. Shortly thereafter, the nurse (Employee #136) arrived at the medication cart and closed the binder, after the situation was brought to her attention. In an interview on 09/19/11 at 7:35 p.m., Employee #136 stated she knew the MAR indicated [REDACTED]. .",2015-01-01
10579,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-09-20,323,E,1,0,KU2H11,". Based on observation and staff interview, the facility failed to maintain a resident environment as free of accident hazards as possible, by staging unused equipment on both sides of the hallway for two (2) of eight (8) hallways observed. Facility census: 119. Finding include: a) Observation of the facility's hallways, beginning at 7:20 p.m. on 09/19/11, found two (2) of eight (8) hallways (with room numbers from 154 to 163 and room numbers 140 to 149) had unused equipment staged on both sides of the halls. The equipment that was staged / not in use included wheelchairs, portable vital sign equipment, a physical therapy storage unit, linen barrels, a wheeled cane, a linen rack, and a linen cart. In an interview on 09/19/11 at 7:25 p.m., a nurse (Employee #136) reported these hallways did not usually have the equipment stored on both sides of the hallways. She further stated, ""I know that the equipment can't block the hallway."" An interview with the administrator, on 09/19/11 at 7:45 p.m., revealed staff was aware that only one (1) side of the hallway can be used to store equipment. Staging or storage of equipment on both sides of a hallway results in a narrowed corridor width that can impede evacuation of residents from the rooms on these hallways in the event of an emergency.",2015-01-01
10580,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,152,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. .",2015-01-01
10581,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,279,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop care plans, for three (3) of fifteen (15) residents reviewed, to reflect each resident's current needs. Resident #56 had experienced a substantial weight gain above her ideal body weight, and this was not reflected in the care plan. Resident #48 was receiving [MEDICAL CONDITION] treatments at an outside facility five (5) days per week, and the plan of care did not mention this. Resident #15 had developed a Stage II pressure ulcer, and this was not reflected in the plan of care. Facility census: 60. Findings include: a) Resident #56 The medical record for Resident #56, when reviewed on 07/28/09, disclosed the resident had been admitted to this facility from another facility on 01/12/09. At the time of admission, the resident was noted to weigh 102 pounds with a height of 62 inches. The initial note completed by the facility's registered dietitian stated her ideal body weight was 110 pounds. Her most recent minimum data set (MDS) assessment, and abbreviated quarterly assessment with an assessment reference date (ARD) of 07/09/09, revealed her weight during the assessment reference period was 119#. The resident's most recent care plan, revised on 07/09/09, stated the resident was ""at nutritional risk related to disease process"". The goal stated, ""Resident will maintain weight."" The interventions determined necessary to address this problem were: ""Monitor intake and provide supplement PRN (as needed). Monitor weight, food and fluid intake. Provide food preferences upon request."" The care plan had not been changed to reflect the resident's surpassing her ideal body weight. b) Resident #48 The medical record of Resident #48, when reviewed on 07/29/09, disclosed a physician's orders [REDACTED].@ 1300 (1:00 pm) last treatment 07/10/09."" The resident's most current care plan, revised on 07/09/09, contained no mention of the resident's [MEDICAL CONDITION]. The facility's administrator, when provided these findings on 07/29/09 at 2:00 p.m., confirmed the care plan made no mention of the [MEDICAL CONDITION] treatments in an outside facility. c) Resident #15 Review of physician's orders [REDACTED]. Review of the facility's Weekly Decubitus Report, dated 06/26/09 to 07/28/09, revealed a Stage II pressure ulcer had been discovered on 06/26/09 and was being treated. Review of the resident's current care plan, dated 06/11/09 to 09/10/09, found it had not been revised to include the development of a Stage II pressure ulcer with interventions developed to promote healing. In an interview on 07/30/09 at 10:00 a.m., the director of nursing (Employee #4) confirmed the care plan had not been revised after the resident developed into a Stage II pressure ulcer. .",2015-01-01
10582,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,280,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of fifteen (15) residents reviewed, to ensure each resident's plan of care was prepared by an interdisciplinary team including all staff involved in the care of the resident and as determined by the needs of the resident. The record record contained two (2) separate care plans, one (1) by facility staff and the other developed by the Hospice Agency contracted to provide care to the residents. Furthermore, the goals of the care plans and interventions to meet those goals were not integrated in a manner to provide the greatest benefit to the resident. Resident identifier: #3. Facility census: 60. Findings include: a) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE], and had been admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's record contained two (2) separate care plans, one (1) developed by facility staff and another developed by the Hospice agency providing care to the resident. The facility's care plan, dated 07/02/09, recognized problems such as risk of alteration in comfort related to decreased mobility, arthritic joints, compression fracture; risk for impaired communication; risk for impaired skin integrity; etc. The Hospice document entitled ""Interdisciplinary Plan of Care"" recognized similar problems, but the interventions stated by the facility were not integrated with those of the Hospice. Neither plan of care displayed involvement of the other entity in its development.",2015-01-01
10583,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,281,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, review of the facility's ""Do not crush list"", and staff interview, it was determined one (1) of three (3) nurses observed (Employee #11) passing medications during the medication observation task failed to provide care for Resident #55 that met current standards of care, by crushing and administering two (2) medications on the list that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, ""I crushed everything except the [MEDICATION NAME]."" Review of the facility's ""Do not Crush list"" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. --- Part II -- Based on record review and staff interview, the facility permitted a nurse to function outside of her scope of practice, by allowing her to order a change in treatment for one (1) of thirteen (13) residents reviewed. Resident identifier: #11. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/28/09, disclosed the resident had been experiencing increased difficulty swallowing, and a swallowing evaluation was completed at 12:35 p.m. on 07/27/09. Following the evaluation, the individual completing the evaluation (unable to read professional title) recommended the resident be ""NPO (nothing by mouth) with alternate method of nutrition / hydration"". When notified at 1300 (1:00 p.m.). the resident's physician gave the following order: ""D/C (discontinue) [MEDICATION NAME], Suction PRN (as needed)."" Later on 07/27/09 at 1815 (06:15 p.m.), a facility nurse had written under the preceding order on a ""physician's orders [REDACTED]. This entry was followed with ""per nursing"" and signed by Employee #27. The DON, when interviewed on 07/29/09 at 10:00 a.m. related to the resident's condition and this finding, stated the resident had not been made NPO by the physician and that deciding to implement a NPO status was not within the scope of practice for a nurse. .",2015-01-01
10584,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,329,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, and review of OBRA's (Omnibus Budget Reconciliation Act of 1987) ""Unnecessary Drugs in the Elderly"", the facility failed to ensure the drug regimen of three (3) of thirteen (13) sampled residents was free from unnecessary drugs. Residents #12, #20, and #11 were receiving medications given in excessive doses, for excessive duration, and/or without adequate monitoring. Resident #12 was receiving [MEDICATION NAME], a sedating drug, in excessive doses not recommended for use in the elderly. Resident #20 had received [MEDICATION NAME], a sedating drug, for excessive duration. Resident #11 had received [MEDICATION NAME], an antipsychotic drug, in excessive doses not recommended for the elderly. Resident identifiers: #12, #20, and #11. Facility census: 60. Findings include: a) Resident #12 Medical record review, on 07/28/09, discovered this [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On admission, the physician ordered [MEDICATION NAME] 1 mg po (by mouth) TID (three-times-a-day) for restlessness / anxiety. Review of July 2009 monthly physician orders [REDACTED]. - [MEDICATION NAME] 1 mg po every four (4) hours PRN (as needed) and may repeat in two (2) hours if not effective for anxiety, originally ordered on [DATE]; - [MEDICATION NAME] (an antipsychotic) 1 mg at HS (hour of sleep), originally ordered on [DATE] for agitation / restlessness; and - [MEDICATION NAME] 0.5 mg every morning, originally ordered on for dementia with agitation. Review of the Medication Administration Record [REDACTED]. Additionally, the resident received a total daily dose of 4 mg of [MEDICATION NAME] on 06/05/09, 06/06/09, 06/07/09, 06/08/09, 06/11/09, 06/27/09, and 06/28/09. According to OBRA's ""Unnecessary Drugs in the Elderly,"" 2 mg is the maximum dose of [MEDICATION NAME] recommended for use in the elderly. This resident was receiving 3 mg routinely and with the PRN order, had occasionally received 4 mg and 5 mg of [MEDICATION NAME] a day. Further review of the June 2009 MAR found the resident had an order for [REDACTED]. Review of nursing notes, from 04/28/09 to present, revealed the resident had been restless frequently and was attempting to get out of a geri-chair; she spent most of her days in the geri-chair. Observations on 07/28/09, from 8:30 a.m. (at which time the resident was already in a geri-chair in the hallway) to 4:30 p.m., found the resident in a geri-chair in the hallway. Medical record review did not find documentation to reflect assessments of the effectiveness of the current pain medication ([MEDICATION NAME] 5/500 mg) or assessments of the resident's level of comfort while seated in the geri-chair (given her [DIAGNOSES REDACTED]. During an interview on 07/28/09 at 3:00 p.m., the director of nursing (DON - Employee #4) was notified of the total daily amounts of [MEDICATION NAME] the resident was receiving, and no further information was provided. This resident was receiving [MEDICATION NAME] in doses not recommended for use in the elderly and [MEDICATION NAME] (an antipsychotic drug) for restlessness / agitation, but the effectiveness of the pain medication had not been re-evaluated, and the resident's comfort level while seated in the geri-chair had not been assessed as a possible cause of restlessness leading to agitation. b) Resident #20 Medical record review, on 07/28/09, discovered this [AGE] year old resident had been receiving [MEDICATION NAME] 50 mg every day for restlessness since 06/13/07, with no dose reductions attempted in an effort to discontinue this medication According to OBRA's ""Unnecessary Drugs in the Elderly,"" [MEDICATION NAME] is not recommended in the elderly due to its potent [MEDICATION NAME] side effects of dry mouth, blurred vision, [MEDICAL CONDITION], constipation, confusion, possible [MEDICAL CONDITION] or hallucinations. Review of the resident's current care plan, dated 06/11/09 to 09/10/09, revealed the resident had an indwelling Foley catheter for urinary obstruction, risk factors of dehydration, disordered thought processes, and constipation, all of which were possible side effects of [MEDICATION NAME] use Observations of this resident, on 07/28/09 and 07/29/09, found him in his room; he slept most of the day and did not respond verbally. In an interview on 07/29/09 at 12:15 p.m., the DON confirmed a gradual dose reduction of [MEDICATION NAME] had not been attempted as required. c) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09, with the terminal [DIAGNOSES REDACTED]. Nursing documentation described episodes of restlessness, trying to climb out of bed, etc., on occasion. On 06/26/09, the resident received a physician's orders [REDACTED]. The resident had received this injection on one (1) occasion in July (07/18/09) when, according to nursing notes, the resident was experiencing ""increased anxiety noted, no relief with nursing interventions"". On 07/20/09, the resident's attending physician gave an order for [REDACTED]. The resident received 15 mg of [MEDICATION NAME] for seven (7) days. On 07/27/09, the [MEDICATION NAME] was discontinued when a speech therapist completed a swallowing evaluation and suggested: ""Pt. (patient) has scheduled [MEDICATION NAME] ordered which is possibly the cause of the severe decline in swallow fx (function)."" The resident had the potential to receive 23 mg of [MEDICATION NAME] in a twenty-four (24) hour period. Review of ""Unnecessary Drugs in the Elderly"" (copyright 1992 and revised in 2002) on page 62 states, for antipsychotic medications, the recommended dose of [MEDICATION NAME] for elderly residents with organic mental syndromes is 4 mg per day. .",2015-01-01
10585,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,386,E,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the attending physician for seven (7) of thirteen (13) sampled residents failed to review the resident's total plan of care with each assessment visit by failing to co-sign visits made by a physician's assistant and other consulting physicians, acknowledging lab values, and acknowledging resident visits to the emergency room . Resident identifiers: #56, #1, #24, #20, #49, #15, and #12. Facility census: 60. Findings include: a) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed the resident's attending physician had visited on 07/26/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing physician's assistant visit to the resident in February or to acknowledge abnormal lab results that had been obtained since his last visit. There was no evidence the physician was aware of these abnormal lab values other than a statement on each ""faxed Dr. (name) NCF I 1/13/09"". There was no signature to signify who had faxed them or that the physician had received the fax. b) Resident #1 The medical record of Resident #1, when reviewed on 07/29/09, disclosed the resident's attending physician had visited on 07/10/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing two (2) visits made to the resident by a physician's assistant on 02/24/09 and 02/26/09. c) Resident #24 The medical record of Resident #24, when reviewed on 07/28/09, disclosed the resident's attending physician had visited the resident on 07/26/09, which was the first visit in several months. Although the physician wrote a progress note at this time, he failed to acknowledge by signing or co-signing a hospital discharge report from 05/04/09 and abnormal lab values obtained on 05/05/09 which had been reviewed by another physician. These documents had been obtained and placed on the resident's record since the last physician's visit and total care review. d) Resident #20 Review of physician's progress notes, on 07/28/09, found the resident had been seen on 05/30/09 by a physician's assistant (PA). Review of the PA's note found staff had been advised to administer Klonopin (a sedative drug) about one (1) hour prior to showering the resident. There was no evidence to reflect the attending physician had acknowledged the note and PA's decisions with initials and date of review as required. Review of physician's progress notes revealed the attending physician had been in the facility and entered a progress note into the record on 07/27/09. e) Resident #49 Medical record review, on 07/30/09, disclosed this resident had been admitted to the facility on [DATE]. Review of physician's progress notes found the resident had been seen by a PA on 05/30/09. Further review of the progress notes found the PA's note had not been co-signed by the attending physician, who had been in the facility and entered a progress note into the record on 07/27/09. f) Resident #15 Medical record review, on 07/30/09, disclosed this resident had been seen by a PA on 02/26/09, 04/30/09, 05/30/09, and 06/03/09. Review of the PA's notes revealed the attending physician had not co-signed the notes indicating agreement with assessments and orders written by the PA. g) Resident #12 Medical record review, on 07/28/09, revealed this resident had been seen by a PA on 05/30/09 and 06/26/09. Review of the PA's notes revealed the notes had not been co-signed by the attending physician indicating agreement with assessments. The attending physician had been in the facility and entered a progress note into the record on 07/27/09. h) During an interview on 07/30/09 at 10:30 a.m., the director of nursing (Employee #4) confirmed the physician had not co-signed the PA's progress notes for Residents 20, #49, #15, and #12. .",2015-01-01
10586,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,387,E,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the attending physician for seven (7) of thirteen (13) residents reviewed failed to complete a physician's visit at least once every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter, as required. Resident identifiers: #24, #56, #1, #41, #12, #49, and #15. Facility census: 60. Findings include: a) Resident #24 When reviewed on 07/27/09, the medical record disclosed this resident had been admitted to the facility on [DATE], following hospitalization for fall resulting in vertebral fracture and a subdural hematoma. Further review disclosed no evidence the resident was seen by her attending physician until 07/26/09. When interviewed on 07/27/09, the facility's director of nursing (DON - Employee #4) could provide no further evidence to reflect the physician had seen the resident at an earlier date. b) Resident #56 When reviewed on 07/28/09, the medical record disclosed this resident had been admitted to the facility on [DATE], having transferred from another facility. Further review disclosed the resident's attending physician had seen her and written a progress note on 01/16/09. A physician's assistant (PA) had visited the patient for a ""chart review"" on 02/26/09. The resident's physician had not made a second visit until 07/26/09. This was confirmed by the DON during an interview at 3:00 p.m. on 07/28/09. c) Resident #1 When reviewed on 07/29/09, the medical record disclosed this resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A progress note, dated 07/10/08, was written by the resident's attending physician. Although the record disclosed numerous physician orders [REDACTED].#1 since that date (07/10/08), until 07/28/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. d) Resident #41 When reviewed on 07/29/09, the medical record disclosed this individual had been a resident of this facility since 2005. When reviewed, it was determined the resident's attending physician had entered a progress note on 04/28/09. A PA had entered a progress note on 05/01/09, and no further visits by a physician or physician extender were documented until 07/26/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. This interval does not meet the requirement that the physician visit the resident every sixty (60) days, which can be alternated with visits by a PA. e) Resident #12 Medical record review, on 07/28/09, discovered this resident had been admitted to the facility on [DATE]. The physician visited and wrote a progress note on 04/28/09. The resident was later seen by a physician's assistant on 05/30/09 and on 06/26/09. There was no evidence to reflect the resident was seen by a physician every thirty (30) days for the first ninety (90) days following admission, as required. f) Resident #49 Medical record review, on 07/30/09, discovered this resident had been admitted to the facility on [DATE]. The entry into the physician's progress notes was made by a PA on 05/30/09. There were no further progress notes until 07/27/09, at which time the resident was seen by the attending physician. There was no evidence to reflect the resident was seen by a physician every thirty (30) days for the first ninety (90) days following admission, as required. g) Resident #15 Medical record review, on 07/30/09, disclosed the attending physician had not alternated visits with the physician's assistant as required. Progress notes revealed the resident had been seen by a PA on 02/26/09, 04/24/09, 05/30/09, and 06/03/09, with no alternating visits by the attending physician. h) During an interview on 07/30/09 at 1:30 p.m., the DON confirmed the attending physician did not make the required visits following admission to the facility or alternate visits with the PA for Residents #12, #49, and #15. .",2015-01-01
10587,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,514,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility staff failed to maintain medical records, for three (3) of fifteen (15) fifteen residents reviewed, in a well organized, accurate, and complete manner. Medical documents and resident information related to services contracted through a hospice provider were not available on the resident's medical record for two (2) residents, and a document completed on an occupational therapy form incorrectly stated several resident diagnoses. Resident identifiers: #11, #3, and #56. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's medical record contained no information related to Hospice. A Hospice nurse (Employee #84) at the facility at that time explained that each Hospice patient had a separate chart for this information. The Hospice record was reviewed. A document titled ""Interdisciplinary Group Meeting"" (with no date) stated the Hospice chaplain visit frequency was ""1 X month (once a month)"". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice nurse was again questioned and stated this documentation would be on his record at the Hospice office. The Hospice nurse agreed the information should be on the record at the nursing facility, and she called the Hospice office to have the documents faxed to the facility. b) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The Hospice record was reviewed. A document titled ""Interdisciplinary Group Meeting"" (with no date) stated the Hospice chaplain visit frequency was ""1 X month"". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice Office was contacted, and this missing documentation was faxed to the facility to be placed on the resident's current medical record. c) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed this [AGE] year old resident was admitted to the facility on [DATE]. The list of [DIAGNOSES REDACTED]. A document entitled ""Plan of Treatment for Outpatient Rehabilitation"" and completed 07/02/09, in Item #20 Initial Assessment, described this resident as having [MEDICAL CONDITION] disorder, nonpsychotic mental disorder, and [MEDICAL CONDITION] in addition to the [DIAGNOSES REDACTED]. On 07/28/09 at approximately 11:00 a.m., the facility's director of nursing (DON - Employee #4) was asked to review this record and determine whether these additional [DIAGNOSES REDACTED]. The DON later confirmed these [DIAGNOSES REDACTED].",2015-01-01
10588,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,332,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. One (1) of three (3) nurses (Employee #11) observed administering medications, with forty (40) opportunities for error, incorrectly crushed two (2) medications for Resident #55 that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, ""I crushed everything except the [MEDICATION NAME]."" Review of the facility's ""Do not Crush list"" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. .",2015-01-01
10589,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,371,F,0,1,OPXH11,"Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 60. Findings include: a) During the initial tour of the kitchen, on 07/27/09 at 1:15 p.m., observation found coffee cups stacked on top of each other on trays. The cups had been stacked prior to complete air drying and had trapped moisture, creating a medium for bacteria growth. b) During the initial tour of the kitchen on 07/27/09 at 1:15 p.m., and during further kitchen observations on 07/29/09 at 11:00 a.m., flies were observed in the food preparation and serving areas. This practice had the potential to result in food contamination and compromised food safety. c) During an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager (Employee #82) confirmed there was trapped moisture in the coffee cups and flies were a problem in the kitchen due to use of the back door located in the kitchen area. .",2015-01-01
10590,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,469,E,0,1,OPXH11,"Based on observation, resident interview, and staff interview, the facility failed to maintain an effective pest control program so the facility was free of flies in the kitchen and resident living areas. During the course of the survey, flies were observed in the facility kitchen and in resident care areas of the facility on the hospital side. A confidential resident interview revealed flies were a problem in resident rooms and in the facility dining areas. This had the potential to affect all residents who reside in the facility. Facility census: 60. Findings include: a) During the initial tour of the kitchen on 07/27/09 at 1:30 p.m., and during additional kitchen observations on 07/29/09 at 11:00 a.m., flies were noted in the food preparation and serving areas of the kitchen. In an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager confirmed flies were a problem in the kitchen due to a back door used in the kitchen area. b) During the medication pass observation task on 07/27/09 at 3:30 p.m., a fly was observed around the medication cart in the hallway in the hospital side of the facility. c) During a confidential resident interview on 07/28/09 at 4:00 p.m., the resident complained that flies were occasionally a problem in both resident rooms and in the resident dining areas. d) During an interview on 07/30/09 at 2:15 p.m., the administrator was informed of the observation and complaint about flies in the facility. .",2015-01-01
10591,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,315,D,0,1,OPXH11,"Based on record review and staff interview, the facility failed to ensure planned interventions for improving a resident's urinary continence status were implemented for one (1) of thirteen (13) residents reviewed. Resident identifier: #56. Facility census: 60. Findings include: a) Resident #56 A comparison of Resident #56's two (2) most recent minimum data set (MDS) assessments disclosed a decline in the resident's urinary continence status. On the MDS with an assessment reference date (ARD) of 04/19/09, the assessor entered a code of ""1"", indicating she was ""occasionally incontinent"". On the MDS with an ARD of 07/09/09, the assessor entered a code of ""2"", indicating she was now ""frequently incontinent"". Review of the resident's most current care plan, revised on 07/09/09, found the following problem statement: ""Risk for alteration in patterns of Urinary Elimination RT (related to) disordered thought processes and infrequent urinary incontinence."" The goal related to this problem stated: ""Resident will not experience further loss of urinary function by review date."" Interventions to achieve this goal included: ""Implement bladder re-training program with all personnel, resident and family if indicated. Observe voiding pattern determine what stimuli precipitate voiding. Comprehensive evaluation of incontinence pattern to determine potential for management program."" A nurse responsible for this resident on 07/29/09 at 3:00 p.m. (Employee #29), when questioned as to what steps were being taken with this resident related to her urinary incontinence, stated the nursing assistants documented each time the resident voids. When further questioned, this nurse stated the resident was not now and, as to her knowledge, never was on a bowel and bladder retraining program. .",2015-01-01
10592,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-09-13,157,D,1,0,XZJR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility did not notify both interested family members when one (1) of five (5) sampled residents had a change in medication, in accordance with the resident's wishes. Resident #66 had informed the facility that two (2) family members were to be notified with any change in condition or treatment. The resident's physician discontinued a pain medication and prescribed another medication. The two (2) family members were not notified of these changes in medication regimen. Facility census: 73. Findings include: a) Resident #66 Record review revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician determined this resident possessed the capacity to understand and make her own informed health care decisions. According to documentation on the resident's admission form, her two (2) sisters were to be notified whenever changes occur in her condition and/or treatment. Further record review revealed the resident was receiving [MEDICATION NAME] 7.5-500 mg once daily for pain beginning on 03/25/11. The order was changed to three (3) times daily with an as needed dose. According to pain assessments, the resident was continuing to have pain, and the physician ordered [MEDICATION NAME] 60 mg daily for the increased pain. The [MEDICATION NAME] was discontinued. The resident started the [MEDICATION NAME] 60 mg daily on 04/09/11. There was no evidence in the resident's chart to reflect the two (2) family members listed on the admission form were notified of changes in the resident's medication regimen. The resident was sent to the hospital on [DATE]. A hospital report dated 04/17/11 revealed: ""Hospital Course - This lady is admitted to the hospital with [REDACTED]. She was treated with intravenous [MEDICATION NAME] and [MEDICATION NAME]. She received nebulizer. She has some upper airway sounds, but her lungs themselves are clear. I believe she needs more help being encouraged to cough. She has difficulty cleaning her secretions. While she was in the hospital she had some right shoulder pain. The above x-rays were done. Nothing in particular was seen. The family became aware that she was on long-acting [MEDICATION NAME]. They wished that to be stopped. I suggested that we simply decrease the dose and this was done. All in all she is improved on discharge. "" According to her hospital records, her discharge [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], and the [MEDICATION NAME] was discontinued and the [MEDICATION NAME] 7.5-500 mg 4 times a day starting on 04/21/11. A physician's progress note, dated 04/18/11, stated: ""Resident (name) was sent to the hospital (name) on 04/11/11 because of increasing confusion and congestion. There were no infiltrates. They felt she had [MEDICAL CONDITION] with exacerbation and acute [MEDICAL CONDITION]. She also has diabetes mellitus which is well controlled with recent hemoglobin A1C of 5.5, hypertension, mild [MEDICAL CONDITION], previous stroke with left sided paralysis and dementia. Her [MEDICATION NAME] stopped at the request of the family and we put her back on the [MEDICATION NAME]."" An interview with the director of nursing, on 09/13/11 at 10:30 a.m., found the resident's two (2) sisters were not notified by the nurse who took off the changes in medication orders. She further stated, ""I spoke with the social worker and she said, the stars were placed on the admission form beside each of the family members' names, and nursing was to call them with any change.""",2015-01-01
10593,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,225,E,0,1,5BYT11,"Based on a review of personnel files and staff interview, the facility failed to adequately screen employees to ensure they were free from personal histories of criminal conviction which would indicate unfitness for service in a nursing facility. The facility did not complete statewide criminal background checks for four (4) of five (5) sampled employees who lived in Ohio. Employees: #1, #2, #3, and #4. Facility census: 95. Findings include: a) Employees #1, #2, #3, and #4 Review of sampled personnel files revealed four (4) of five (5) new employees lived in another State (Ohio). Further review failed to find evidence of statewide criminal background checks completed for this individuals in that State. Interview with human resources personnel, on the late morning of 05/22/09, verified the above findings. .",2015-01-01
10594,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,253,E,0,1,5BYT11,"Based on observation and staff interview, the facility failed to assure the doors to resident rooms, bathrooms, and closets were in good repair. Ten (10) doors observed on the 200 Hall were in need of repair, with deep scratches and holes in the doors making these surfaces difficult to clean thoroughly. This was true for one (1) of four (4) hallways observed. Facility census: 95. Findings include: a) 200 Hall During a tour of the facility on 05/19/09 at 9:30 a.m., observation found doors to resident rooms, bathrooms, and closets on the 200 Hall were in poor condition, with deep scratches and holes in need of repair. The doors were for the following rooms: 201, 202, 204,205, 206, 207, 209 210, 211, and 212. During a tour with the maintenance personnel, staff confirmed these doors were scratched and/or had holes in them. .",2015-01-01
10595,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,272,D,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure one (1) of thirty-two (32) residents reviewed during Stage II of the survey was assessed for fluid needs. Resident #106, admitted about one (1) week ago, was receiving [MEDICAL TREATMENT] three (3) times a week, and her record contained no evidence of any assessment with respect to daily fluid needs. After surveyor intervention, the [MEDICAL TREATMENT] center's physician ordered a fluid restriction of 1500 cc daily. Facility census: 95. Findings include: a) Resident #106 Resident #106 was a fairly new admission of one (1) week's duration whose interim care plan did not address her daily fluid needs. Interview with Resident #106, on 05/21/09 at 11:30 a.m., revealed she was unaware of any type of fluid restriction. She also seemed somewhat confused at this time. Medical record review, on 05/21/09 at 2:35 p.m., revealed no physician orders dictating the amount of daily fluids allowed for this resident who received [MEDICAL TREATMENT] treatments three (3) times weekly. On 05/21/09 at 2:35 p.m., a staff nurse (Employee #25), when interviewed regarding fluid needs for this resident, reviewed the medical record and plan of care and agreed there was no order regarding daily fluid intake. She stated she thought there was no fluid restriction for this resident or, perhaps, the order got lost between the physicians. She immediately called the [MEDICAL TREATMENT] center, received an order for [REDACTED]. .",2015-01-01
10596,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,279,D,0,1,5BYT11,"**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 thirty-two (32) residents in Stage II. The antipsychotic medication of Resident #53, with a history prior to admission of exhibiting violent behavior, was discontinued, and the care plan did not direct staff to monitor the resident for a resurgence of violent behavior following discontinuation of the drug, did not identify non-pharmacologic approaches to use when the behavior occurred, and did not specify the therapeutic goal(s) of the other psychoactive medications the resident was still receiving. Resident #219 was admitted for falls and decreased mobility, and care plans for not developed to address either of these concerns. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. ""According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)."" Record review resident's admission orders [REDACTED]""agitation"", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for ""anxiety."" A hospital history and physical examination [REDACTED]."" A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, ""Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3."" On 04/05/09 the 10:00 a.m., a nurse wrote, ""In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse."" A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICATION NAME]. On 05/14/09 the 9:00 a.m., a nurse wrote, ""Rsdt (resident) down in bed Nursing Assistants at bedside providing care rsdt. Bent thumb of (nursing assistant) back while turning to change soiled brief."" A confidential interview with a nursing assistant who periodically cared for Resident #53, on day shift on 05/21/09, the resident would sometimes try to ""stabilize himself ... like reaching out for support, rather than trying to be abusive."" On 05/21/09 at 2:00 p.m., the administrator, when interviewed, verified a care plan was developed for the resident and included the use of psychoactive medications, but no plan was developed with respect to monitoring for and responding to violent behaviors after the [MEDICATION NAME] was discontinued. The 04/15/09 care plan for the use of psychoactive medication used terms such as: ""He becomes agitated easily and becomes anxious due to the confusion."" One (1) intervention was: ""Monitor behavior every shift and document."" However, it did not describe the type of the behaviors to be monitored (violent physical aggression), did not provide direction to staff regarding how to respond to those behaviors, nor did the care plan provide any therapeutic goals for the resident's use of these psychoactive medication. The stated goal was: ""Resident will be free of any discomfort of adverse side effects."" b) Resident #219 Review of Resident #219's medical record revealed he was admitted at 6:50 p.m. on 05/18/09, with [DIAGNOSES REDACTED]."" The initial care plan, developed to capture the immediate care needs for this resident, did not address falls. The pre-printed initial care plan for ""fall / safety risk"" was blank, even though this was why he was admitted to the facility. According to the nursing notes, on 05/20/09 at 11:30 p.m., the resident was outside smoking when he fell while getting up from a chair. There was no evidence a falls care plan was initiated after this fall occurred. .",2015-01-01
10597,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,280,D,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to review and revise a resident's care plan when the reason for use of an indwelling Foley urinary catheter changed. This was true for one (1) of thirty-two (32) residents in the Stage II sample. Resident identifier: #78. Facility census: 95. Findings include: a) Resident #78 Medical record review revealed a care plan, written on 02/05/09, addressing the presence of an indwelling Foley urinary catheter. According to this care plan, the problem stated: ""Risk for infection indwelling catheter d/t (due to) pressure area (hx of UTI'S) (history of urinary tract infections). The three (3) goals associated with this problem were: 1) ""Resident will be free of complications of indwelling catheter daily"", 2) ""Will remain free from s/s (signs and symptoms) of UTI by next review date, and 3) ""Foley will be d/c (discontinued) as condition and mobility improve prior to d/c (discharge) home."" There was no evidence found in the medical record to show that, on 02/05/09, Resident #78 had pressure ulcers necessitating the use of an indwelling urinary catheter as stated in the plan of care. A quarterly care conference was held on 04/29/09, but the use of this catheter was not reviewed. There was no evidence, as of 05/20/09, to reflect this care plan had been reviewed or revised. Further review of the medical record revealed this catheter had been discontinued and was subsequently reinserted due to the resident's [MEDICAL CONDITION]. During an interview on 05/22/09 at 10:30 a.m., the care plan nurse confirmed this care plan should have been reviewed and revised during the 04/29/09 care plan meeting. After surveyor intervention, a new physician's orders [REDACTED]. .",2015-01-01
10598,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,309,D,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, resident interview, and policy review, the facility failed to establish parameters for the administration of pain medication when multiple pains medications were ordered; failed to document the effectiveness of PRN pain medication after it was given; and failed to report to the physician when ""as needed"" (PRN) medications were used frequently, so the physician would order around-the-clock pain medication for increased pain management. This was evident for three (3) of thirty-two (32) Stage II residents reviewed for pain management. Resident identifiers: #135, #9, and #137. Facility census: 95. Findings include: a) Resident #135 During an interview on the afternoon of 05/19/09, Resident #135 expressed pain in his stomach. Interview with the resident's nursing assistant (Employee #83), at 9:10 a.m. on 05/21/09, revealed Resident #135 did reported stomach pain and received medication for this symptom. Interview with the licensed practical nurse (LPN - Employee #16), at 10:45 a.m. on 05/21/09, revealed the resident expressed stomach discomfort, and this had also been reported by the resident's wife. The wife confirmed this at lunch time when interviewed on 05/21/09. She reported he had an ongoing problem with stomach pain for which they had not been able to determine the cause. He received [MEDICATION NAME], and this brought relief. A review of his medical record revealed Resident #135 had orders for Tylenol 325 mg two (2) tablets by mouth every four (4) hours PRN for pain and [MEDICATION NAME] with [MEDICATION NAME] 10-500 mg tablet by mouth every six (6) hours PRN for pain with a pain assessment to be completed every morning. The pain assessment was to include asking the resident what level the pain he was experiencing prior to medication administration on a scale from ""0"" to ""10"", with ""10"" being the worst. Review of the May 2009 Medication Administration Record [REDACTED]. On the reverse side of the MAR, staff did not always record whether the medication was effective, with such documentation found on only eight (8) or twenty-two (22) days. The notations on the reverse of the form indicated Resident #135 received this medication for back pain on six (6) of the eight (8) dates and for general pain on the other two (2) dates. The presence of back pain had not been identified until these entries were reviewed. There were no parameters to direct staff as to which of these pain medications (Tylenol or [MEDICATION NAME]) was to be administered when the resident reported pain or discomfort, leaving the choice of medication to the discretion of the nurse. During a discussion with the administrator, on the mid-morning of 05/22/09, it was confirmed that the nursing staff failed to obtain clarification orders from the physician to establish the parameters for administering these pain medications. A written policy (with an effective of August 2000) was presented to the surveyors indicated the attending physician must periodically review the resident's use and need for PRN medications, to determine if it needs to be changed or discontinued. No evidence that this occurred was presented by the time of survey exit. b) Resident #9 Review of the May 2009 monthly recapitulation of physician's orders [REDACTED]. The orders did not provide parameters to direct the nursing staff as to when to select one (1) pain medication over specify another for the treatment of [REDACTED]. c) Resident #137 Review of the May 2009 monthly recapitulation of physician's orders [REDACTED]. The orders did not provide parameters to direct the nursing staff as to when to select one (1) pain medication over specify the other for the treatment of [REDACTED]. .",2015-01-01
10599,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,323,D,0,1,5BYT11,"Based on observation, review of manufacturer's instructions for the application of a wrist restraint, and staff interview, the facility failed to apply a physical restraint, to one (1) of thirty-two (32) residents in the Stage II sample, in accordance with the manufacturer's instructions. Resident #137 was observed with the wrist restraint secured to the side rail, rather than the bed frame per the manufacturer's instructions. This practice placed the resident at risk for an accident. Facility census: 95. Findings include: a) Resident #137 On 05/21/09 at 11:00 a.m., observation by two (2) surveyors found the resident with a wrist restraint tied to the side rail. The side rail was a one-quarter length rail raised to an approximate forty five degree position, and the wrist restraint was tied to the bottom part of the rail. The resident was then observed with the director of nursing (DON) immediately after the first observation. Per the DON, the wrist restraint was applied to prevent the resident from pulling out a tracheostomy and a feeding tube. The DON indicated, during the observation, that the wrist restraint should not have been tied to the side rail, but should have been tied to the bed frame. According to the product's instructions, the device should have been secured to the movable part of the bed frame. .",2015-01-01
10600,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,329,D,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (1) of thirty-two (32) residents in the Stage II sample. Resident #53 was admitted to the facility on [DATE] with physician's orders [REDACTED]."", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for ""anxiety."" These medications were used in an excessive dose (duplicate therapy), without adequate monitoring for the resurgence of behaviors after the Zyprex was discontinued, and without monitoring to evaluate the efficacy of the medications and for possible adverse side effects. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. ""According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)."" Record review resident's admission orders [REDACTED]""agitation"", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for ""anxiety."" A hospital history and physical examination [REDACTED]."" A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, ""Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3."" On 04/05/09 the 10:00 a.m., a nurse wrote, ""In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse."" A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICATION NAME]. On 05/14/09 the 9:00 a.m., a nurse wrote, ""Rsdt (resident) down in bed Nursing Assistants at bedside providing care rsdt. Bent thumb of (nursing assistant) back while turning to change soiled brief."" A confidential interview with a nursing assistant who periodically cared for Resident #53, on day shift on 05/21/09, the resident would sometimes try to ""stabilize himself ... like reaching out for support, rather than trying to be abusive."" On 05/21/09 at 2:00 p.m., the administrator, when interviewed, verified a care plan was developed for the resident and included the use of psychoactive medications, but no plan was developed with respect to monitoring for and responding to violent behaviors after the [MEDICATION NAME] was discontinued. The 04/15/09 care plan for the use of psychoactive medication used terms such as: ""He becomes agitated easily and becomes anxious due to the confusion."" One (1) intervention was: ""Monitor behavior every shift and document."" However, it did not describe the type of the behaviors to be monitored (violent physical aggression), did not provide direction to staff regarding how to respond to those behaviors, nor did the care plan provide any therapeutic goals for the resident's use of these psychoactive medication. The stated goal was: ""Resident will be free of any discomfort of adverse side effects."" Medical record review also an absence of monitoring for target behaviors to assess the efficacy of the medications and for possible adverse side effects. An interview with the director of nursing, on the late afternoon of 05/21/09, found the forms used by facility staff for monitoring of behaviors and adverse side effects of psychoactive medications; these forms had not been completed for Resident #53 for either April or May 2009. .",2015-01-01
10601,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,463,E,0,1,5BYT11,"Based on observation and staff interview, the facility's call alarm system was altered and not functioning as intended for the 100 Hall. The ceiling-mounted speaker used for the nurse call system's auditory alarm was covered with tape to make the volume too low to be heard by staff on the unit; the auditory alarm could only be heard at the nurses' station. Additionally, the length of the pull cord for call light in the bathroom of Room #113 was too short to be reached from the toilet if the resident needed to summon staff assistance. This deficient practice had the potential to affect all twenty-five (25) residents residing on 100 Hall. Facility census: 95. Findings include: a) Nurse call system on 100 Hall When verifying the functionality of the nurse call system on the 100 Hall on 05/21/09 at 11:00 a.m., observation revealed the visual alarm activated in the corridors above each resident doorway, and an auditory alarm sounded at the nurses' station. However, an auditory alarm could not be heard sounding on the hall itself. The environmental supervisor (Employee #103) went to the speaker where the sound should have been coming out and found the speaker was covered with surgical tape, which muted the auditory alarm. When the tape was removed, the alarm was audible from the speaker. The environmental supervisor verified the tape should not have been on the speaker. b) Call light for Room 113's bathroom Observation of the nurse call system serving the bathroom in Room 113 revealed the pull was only approximately 2 inches in length. A resident using the toilet, or a resident having fallen to the floor, would not have been able to reach the pull cord to summon assistance. The environmental supervisor was made aware of light, and a new pull cord was installed. . Resident 1: call alarms were covered with tape and inaudible",2015-01-01
10602,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,514,B,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1: oxygen tubing treatment sheets not complete Based on observation, medical record review, and staff interview, the facility failed to each resident's clinical record was accurate and complete. Staff failed to document weekly oxygen tubing changes ordered by the physician. Resident identifiers: #2188 and #3439 on the 400 Hall, and Residents #3163 and #1889 on the 100 Hall. Facility census : 95. Findings include: a) Residents #2188, #3439, #3163, and #1889 During random observations during tour on 05/19/09 and during resident interviews on the day of entry, four (4) residents were observed to have no dates on their oxygen tubings to indicate when they had most recently been changed. Also, there was no documentation on the residents' treatment records to reflect the tubing had been changed weekly as the physician had ordered. 1. Residents #2188 and #3439 On the 400 Hall on 05/19/09 at 9:30 a.m., Residents #2188 and #3439 were noted to have oxygen concentrators in use with no dates to show when the tubing had been changed. The filters on both concentrators were dirty. On 05/20/09 at 9:55 a.m., interview with the charge nurse (Employee #26) revealed the facility did not have a separate respiratory therapy department. Rather, a nurse came to the facility twice weekly, and she changed all the oxygen tubing in the facility on Fridays. Employee #26 also reported they had aides change the tubing if the nurse is not there. The charge nurse and surveyor checked the residents' treatment records and found Resident #2188's tubing change was not recorded for 05/08/09, and Resident #3439's tubing change was not recorded for 05/08/09 or 05/15/09. Both residents had orders for oxygen tubing to be changed weekly. The director of nursing (DON), who was present at this time, stated oxygen tubing was changed weekly in the facility and, when told of the above findings, said they would take care of it right away. 2. Residents #3163 and #1889 On the 100 Hall on 05/19/09 at 4:30 p.m., Residents #3163 and #1889 were noted to have oxygen concentrators with no dates on their tubings to indicate then they had last been changed. Also, Resident #3163's humidifier bottle contained about one-half inch of water, and Resident #3163's humidifier bottle had less than one-half inch of water. Review of the residents' treatment records revealed blank spaces where oxygen tubing changes were to have been recorded. Neither resident's record had been written on or initialed in the month of May 2009. Physician orders [REDACTED]. On 05/20/09 at 5:00 p.m., the nurse (Employee #15) said Resident #3163 receives nebulizer treatment four (4) times daily and wears her oxygen about two days weekly, and Resident #1889 wears oxygen two (2) to three (3) days per week. This surveyor observed both residents wearing oxygen for intervals on every day of the survey. 3. On 05/22/09 at 11:00 a.m., this surveyor asked the administrator for the facility's policy on changing oxygen tubing. She said they had no written policy, but staff changed the tubings weekly and recorded the changes on the residents' treatment records. This surveyor then gave her the names and room numbers of the above four (4) residents who had no documentation of weekly tubing changes as ordered by the physician.",2015-01-01
10603,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2011-09-08,425,D,1,0,9J3I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of eight (8) residents reviewed, to provide medications as ordered by the physician in a timely manner. The resident was ordered an antibiotic that was available in the facility's emergency drug kit, but staff did not administer the first dose of this antibiotic until over twenty-four (24) hours after it was ordered. Resident identifier: #91. Facility census: 99. Findings include: a) Resident #91 When reviewed on 09/08/11, the medical record of Resident #91 revealed a physician's orders [REDACTED]. (There was no time of day associated with this order.) According to the resident's Medication Administration Record [REDACTED]. The unit manager for Hilltop Unit (Employee #104), when questioned related to this delay in administering the medication, confirmed that Cipro was kept in the emergency medication box and should be available at all times. She further stated she did not know why the medication was not started on 08/09/11 (when ordered). The unit manager reviewed the record and found the order was entered into the computer at 5:45 p.m. on 08/09/11 by the nurse who received the order. The first dose of Cipro was not administered until 8:00 p.m. on 08/10/11, even though the medication was in the facility at the time it was ordered. The unit manager agreed this was not acceptable and that the medication should have been started when it was ordered. .",2015-01-01
10604,SALEM CENTER,515071,146 WATER STREET,SALEM,WV,26426,2011-09-08,431,D,1,0,9J3I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of eight (8) residents reviewed, to assure the accurate labeling of medications. an order for [REDACTED].#91. Facility census: 99. Findings include: a) Resident #91 When reviewed on 09/08/11, the medical record for Resident #91 revealed the resident's anti-seizure medication had undergone numerous dosage changes in recent weeks. The resident's available medications were reviewed in the medication cart. The medication Dilantin was available in two (2) boxes. - The label on one (1) box read: ""Dilantin Infatabs Chew 50 mg give 1 tab by mouth twice daily. Take with 200 mg = 250 mg."" - The label other the box read: ""Phenytoin Sodium ER 100 mg capsule Generic for Dilantin, give 3 caps Q (every) morning and 1 cap by mouth every evening."" The most recent medication change had occurred on 08/29/11 and was for the resident to receive 250 mg twice daily. The resident's Medication Administration Record [REDACTED] When interviewed on 09/08/11, a licensed practical nurse (LPN - Employee #50) was asked how the medication labels were updated when the ordered dosage is changed. This employee stated the pharmacy was notified, and when a new order was received, the label would be correct (after the current meds had been administered). The facility's Pharmacy Policy Manual was requested and received. The policy titled ""4.4 Reordering, changing, and discontinuing orders"" stated, on Page 2 ""3.5. If the Pharmacy receives a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand:"" ""... 3.5.3. Facility should notify the Pharmacy not to send the medication. The facility should attach a 'change in directions' sticker to the existing quantity of medications until the pharmacy permanently affixes the label to the medication package or container."" These medication boxes contained no such ""change in direction"" stickers, and this was confirmed by Employee #50.",2015-01-01
10605,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,152,E,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. ""Determination of incapacity. ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..."" - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the social worker (SW - Employee #188) revealed the above residents' determinations of capacity were based on a medical [DIAGNOSES REDACTED]. Both employees agreed that, just because a resident was hard of hearing, this did not necessarily mean the resident lacked the capacity to understand and make informed health care decisions. -- b) Resident #9 1. Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions. The document signed by the physician contained no date of the determination. ""Dementia"" was written across the areas on the form on which documentation was supposed to include ""nature of incapacity"" and ""cause of incapacity"". (The documentation of ""dementia"" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) - 2. According to WVC 16-30-7: ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. The section on the facility's form regarding this requirement required the indication of ""yes"" or a ""no."" Neither ""yes"" or ""no"" was marked. - 3. During an interview on 09/29/11 at 10:30 a.m., the acting DON confirmed this determination of incapacity did not describe why the resident could not make her own health care decisions, did not contain a date, and did not indicate the resident had been informed of being deemed incapacitated to make health care decision by the physician. -- c) Residents #5 Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions on 11/23/10. ""Dementia"" was written across the areas on the form on which documentation was supposed to include ""nature of incapacity"" and ""cause of incapacity."" (The documentation of ""dementia"" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) During an interview on 09/29/11 at 10:30 a.m., the DON confirmed this resident's determination of incapacity did not describe why the resident could not make her own health care decisions. .",2015-01-01
10606,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,309,D,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide services and care for two (2) of eight (8) sampled residents. Resident #35 was in the facility for seven (7) days with no bowel movement before interventions were implemented for constipation. Resident #39 was noted by a nurse to have experienced a possible ""change in condition"", for which there was no description, no assessment, and no evidence of follow-up. Resident identifiers: #35 and #39. Facility census: 38. Findings include: a) Resident #35 Record review revealed Resident #35 was admitted on [DATE]. The bowel elimination record revealed no recorded bowel movements until 06/14/11. A small hard bowel movement was recorded on this date. Bowel movements were recorded daily through 06/20/11. From 06/21/11 through 06/24/11, the resident did not have a bowel movement. An order was obtained on 06/25/11 for milk of magnesia (MOM) 30 cc every three (3) days as needed (PRN) for constipation. On 06/25/11 and 06/26/11, there were eight (8) extra, extra large bowel movements recorded. There were no recorded bowel movements from 06/27/11 through 07/03/11, when the record revealed the resident had a large bowel movement. The Medication Administration Record [REDACTED]. On 09/29/11 at 2:32 p.m., an interview with the director of nursing (DON - Employee #169) and the vice president of patient care (Employee #134) revealed there was no formal protocol for staff to follow regarding constipation. Employee #134 stated, ""It was understood, an order would be obtained for the resident to receive milk of magnesia every three days, if they had not had a bowel movement."" This employee further agreed there was ""a lack of consistency"" in doing this. -- b) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible ""COC"" (change of condition). The note indicated the resident ""seemed dazy"". The situation was serious enough the nurse documented she believed the resident should be sent to the emergency room (ER). The family was contacted but did not want the resident sent to the ER. There was no evidence the physician was contacted. Vital signs were documented on the note dated 06/10/11 at 02:21 (2:21 a.m.); however, this note contained no documentation describing the COC. The next note was on the same date at 03:11 (3:11 a.m.), which described the resident was sleeping. There were no further nursing notes until 06/13/11 at 04:49 (4:49 a.m.). This note was not related to the COC; rather, the note identified that the resident had fallen and was complaining of left hip pain. She was then sent to the ER. After the initial entry identifying a possible COC, there was no evidence of any other assessment or follow-up regarding the possible COC on 06/10/11. Interview with the acting director of nursing (DON - Employee #171), at 10:15 a.m. on 09/30/11, confirmed COC meant ""change of condition"". Employee #171 also confirmed there was no description of the COC, no continuing assessment of the COC, and no follow-up of the COC. All of these components were necessary to assure the provision of the highest practicable care and services for this resident. .",2015-01-01
10607,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,329,D,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to assure the medication regimens of three (3) of eight (8) sampled residents were free from unnecessary medications. These residents were given medications without evidence of need, without attempts at non-pharmacological interventions, without adequate assessment of possible causes for changes in behavior, and/or without adequate monitoring. Resident identifiers: #9, #5, and #35. Facility census: 38. Findings include: a) Resident #5 Medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. She had been receiving [MEDICATION NAME] 100 mg at hs (bedtime) since 06/23/11. On 07/04/11, the dosage of [MEDICATION NAME] was doubled to 100 mg twice a day. Review of the resident's nursing notes, dated 07/01/11, revealed the resident was more agitated and was going to the bathroom more frequently. A urine culture and sensitivity was ordered on that date. On 07/02/11, the resident was ordered Bactrim DS twice daily for three (3) days, then Bactrim 80/400 mg daily ""ongoing"". (Bactrim is an antibiotic medication used frequently for a urinary tract infections [MEDICAL CONDITION].) On 07/04/11, nursing notes described the resident was ""Very mobile while up in w/c (wheelchair). Goes from one door to another door setting off alarm. In constant motion & movement. Wanderguard system functioning well. Still on po (by mouth) antibiotic therapy ..."" There was no evidence of attempts at redirection or other non-pharmacological interventions. Additionally, there was no evidence that possible causal factors for the behaviors had been assessed. On 07/04/11 at 20:00 (8:00 p.m.), a verbal order was received to increase the [MEDICATION NAME] from 100 mg daily to 200 mg daily. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed there was no evidence of need for this increased dosage of [MEDICATION NAME], because the resident had a UTI which most likely caused the changes in her behaviors. The resident was ordered an increased dosage of [MEDICATION NAME] without evidence of consideration that the UTI might be causing the changes in her behaviors. Once the UTI was resolved, the resident's behaviors may have dissipated without pharmacological interventions for behaviors. -- b) Resident #9 Medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. On 09/08/11, a telephone order was obtained for [MEDICATION NAME] 0.25 mg three (3) times daily as needed (PRN) for anxiety. Review of nursing notes, from 08/28/11 through 09/08/11, revealed no documentation of anxiety, or anything reflective of a need for an order for [REDACTED]. Documentation dated 09/07/11 revealed the resident was in the dining room for lunch and was non-compliant with her fluid restriction. She had no signs or symptoms of distress, no shortness of breath, no complaints of pain, and took her medications without difficulty. On 09/08/11, nursing notes included, ""Resident's cond. (condition) unchanged. Alert and friendly /c (with) staff. Meds (medications) po (by mouth) /s (without) difficulty..."" Interview with Employee #171, at 10:30 a.m. on 09/29/11, confirmed that, based on information in the medical record, there was no evidence of need for the PRN order for [MEDICATION NAME]. Employee #171 was unable to explain why the [MEDICATION NAME] was ordered for this resident. -- c) Resident #35 Resident #35 was observed on 09/28/11 at 3:00 p.m., in bed with the covers thrown off and continuously moving in her bed. A review of Resident #35's medical record, on the early afternoon of 09/29/11, revealed an order for [REDACTED]. On 06/22/11 at 15:50 (3:50 p.m.), the resident was given [MEDICATION NAME] for restlessness. The nurse's notes described the resident as trying to get out of bed, rolling from side to side in bed, and constantly moving. On 06/25/11 at 15:00 (3:00 p.m.), nurse's notes revealed there were no bowel movements for several days and milk of magnesia was given as ordered. This resident was described, in the nurse's notes, as restless, rolling back and forth in bed, and trying to get out of bed. The Medication Administration Record [REDACTED]. In an interview with the director of nursing (Employee #169) on 09/29/11 at 2:32 p.m., Employee #169 agreed Resident #35 was constantly moving back and forth in her bed and that this was the resident's ""normal"" behavior. She also agreed the [MEDICATION NAME] should not have been given, as this behavior was not unusual for the resident. .",2015-01-01
10608,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,151,D,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, ""You're not giving me no shot."" The resident was walked to her room, all the while screaming ""No, no, no."" Nurse's notes described the resident as ""shaking all over"" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because ""she does not like how it makes her feel."" It should be noted that [MEDICATION NAME] was one (1) of the medications the resident had refused to take by mouth. The resident's rights were violated when the resident refused [MEDICATION NAME] by mouth and was forced to take the same medication by injection. On 06/13/11, the facility again attempted to violate this resident's rights. Nurse's notes, on 06/13/11 at 05:55 (5:55 a.m.) revealed another telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". Nurse's notes continued with, ""... Unable to give resident shot. Became very agitated and belligerent and defensive. Not enough staff available @ this time to assist. She refuses to have [MEDICATION NAME]."" Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed that a discussion should have been held with the resident regarding cleaning of her room. Additionally, Employee #171 confirmed the resident should have been afforded the right to refuse the [MEDICATION NAME], and staff violated the resident's rights when they did not allow the resident to refuse the injection of [MEDICATION NAME] on 06/10/11. .",2015-01-01
10609,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,222,D,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of eight (8) sampled residents had the right to be free from chemical restraints. This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, ""You're not giving me no shot."" The resident was walked to her room, all the while screaming ""No, no, no."" Nurse's notes described the resident as ""shaking all over"" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because ""she does not like how it makes her feel."" It should be noted that [MEDICATION NAME] was one (1) of the medications the resident had refused to take by mouth. Nurse's notes, on 06/13/11 at 05:55 (5:55 a.m.) revealed another telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". Nurse's notes continued with, ""... Unable to give resident shot. Became very agitated and belligerent and defensive. Not enough staff available @ this time to assist. She refuses to have [MEDICATION NAME]."" This resident was given [MEDICATION NAME] for staff convenience. It was used without assessing possible causes for the resident's behavior and without evidence of attempts at planned and individualized non-pharmacological interventions, prior to the decision to use a medication. The facility used medication as a means of managing the resident's behavior with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. As such, this resident was chemically restrained. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed this resident should have been afforded the right to refuse the [MEDICATION NAME], and staff violated the resident's rights when they did not allow the resident to refuse the injection of [MEDICATION NAME] on 06/10/11. Employee #171 also confirmed staff should have tried non-pharmacological interventions, and she confirmed there was no evidence that staff had attempted any non-pharmacological approaches prior to the decision to use a medication to control the resident's behaviors. .",2015-01-01
10610,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,250,D,1,0,0VZD11,". Based on medical record review and staff interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-bring for two (2) of eight (8) sampled residents. The facility failed to assure staff was knowledgeable regarding the provision of alternatives to drug therapy and/or chemical restraints. Additionally, there was no evidence staff understood why residents act as they do, what residents are attempting to communicate by their actions, and what individual needs the staff must meet for each resident. Resident identifiers: #41 and #5. Facility census: 38. Findings include: a) Resident #41 This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. There was no evidence staff were assisted in understanding this resident had a right to autonomy and self determination, so taking away these rights resulted in unacceptable behaviors, resulting in a chemical restraint. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for ""Ativan 1 mg IM now"". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, ""You're not giving me no shot."" The resident was walked to her room, all the while screaming ""No, no, no."" Nurse's notes described the resident as ""shaking all over"" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because ""she does not like how it makes her feel."" It should be noted that Ativan was one (1) of the medications the resident had refused to take by mouth. Although the resident had the capacity to understand and make her own health care decisions, she was not allowed to refuse the Ativan on 06/10/11. When staff forced the resident to take the injection of Ativan on 06/10/11, they chemically restrained the resident, as well as violated her rights. (See also citations at F151 and F222.) -- b) Resident #5 Resident #5 had been receiving Seroquel 100 mg at hs (bedtime) since 06/23/11. On 07/04/11, the dosage of Seroquel was doubled to 100 mg twice a day. On 07/04/11, nursing notes described the resident was ""Very mobile while up in w/c (wheelchair). Goes from one door to another door setting off alarm. In constant motion & movement. Wanderguard system functioning well..."" There was no evidence of attempts at redirection or other non-pharmacological interventions. Additionally, there was no evidence that possible causal factors for the behaviors had been assessed. On 07/04/11 at 20:00 a verbal order was received to increase the Seroquel from 100 mg daily to 200 mg daily. This resident was ordered additional medication without evidence of need, without attempts at non-pharmacological interventions, and without adequate assessment of possible causes for behaviors. There was no evidence staff was assisted in understanding why this resident exhibited behaviors, and no evidence of exploration of non-pharmacological interventions based upon the individual circumstances and needs of the resident. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed facility staff should have tried non-pharmacological interventions, and confirmed there was no evidence facility staff had attempted non-pharmacological approaches prior to the decision to use a medication to control the resident's behaviors. .",2015-01-01
10611,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,514,D,1,0,0VZD11,". Based on medical record review and staff interview, the facility failed to assure the clinical record for one (1) of eight (8) sampled residents was complete. This resident was noted to have a change in condition. The documentation regarding this change in condition did not contain enough information to indicate staff knew the status of the resident. This documentation was needed to assure necessary care and services were provided the resident. Resident identifier: #39. Facility census: 38. Findings include: a) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible ""COC"" (change of condition). The note indicated the resident ""seemed dazy"". The situation was serious enough the nurse documented she believed the resident should be sent to the emergency room (ER). Vital signs were documented on the note dated 06/10/11 at 02:21 (2:21 a.m.). The note contained no documentation which described the COC. There were no further nursing notes until 06/13/11 at 04:49 (4:49 a.m.). The contents of this note were not related to the COC. Interview with the acting director of nursing (DON - Employee #171), at 10:15 a.m. on 09/30/11, confirmed COC meant ""change of condition"". Employee #171 also confirmed there was no description of the COC, which was necessary to assure the optimum provision of care and services for this resident.",2015-01-01
10612,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-09-21,225,D,1,0,CW0X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's resident concern forms, staff interview, and review of policies and procedures, the facility failed to assure allegations of mistreatment, abuse, neglect, and/or misappropriation of resident property (made by a resident or any person acting on behalf of a resident) were reported to State officials as required by law. Review of the facility's concern forms found allegations of abuse / neglect that were not immediately reported to State officials as required by law. This deficient practice was true for three (3) of thirty-five (35) grievance / concern forms reviewed, involving two (2) residents. Resident identifiers: #132 and #157. Facility census: 153. Findings include: a) Resident #132 1. Review of the facility's resident concern forms found a record of a complaint voiced by Resident #132 dated 08/03/11, stating: ""1. Resident complaining that her buttocks has been hurting and staff haven't been putting the cream on which is provided by the facility. 2. Ears packed and needs cleaned out. 3. Teeth aren't being cleaned regularly. 4. Flies in the room. 5. Roommates BSC (bedside commode) didn't have a lid on it and when asked to fix this the nurse just pulled the curtain. 6. Resident was cold and asked for the air conditioner to be turned down and the family heard per telephone a staff member turning it up. 7. When the current roommate was admitted she yelled for several nights and kept the pt. (patient) awake. When family complained (name of nurse) explained that the issue would be resolved in six hours. They took (name of this resident) to the dining room during this time and the issue was resolved. There are no current issues between pt. (patient) and the roommate. The family doesn't understand why pt. (patient) had to remain in the dining room. 9. Sunday 07/31 (name of resident) and (name of another resident) were left in the dining room from breakfast time until after lunch. They were yelling for help and no one checked on them. They called (name of other resident's sister) from (name of other resident's) cell phone to call for help."" Although not all the individual concerns constituted allegations of abuse or neglect, the resident did allege she did not receive goods and services necessary to avoid physical harm and mental anguish and that she was a victim of involuntary seclusion, both of which should have been reported to State officials. Further review of the concern form revealed the following documented as a resolution to the above: ""Order written for [MEDICATION NAME] BID (two times a day) to coccyx on 08/08/11. Will refer to wound team and [MEDICATION NAME] and irrigation of order written. Oral care inservice in progress to all CNA's (certified nursing assistants)."" - During an interview with the administrator and director of nursing (DON) on the morning of 09/21/11, the administrator explained the facility had investigated the allegations and had taken statements from staff but had not reported the allegations to State officials. There was no evidence the facility reported the allegations of neglect / neglect to State officials when the resident voiced the above concerns on 08/03/11. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""... The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). ..."" - The Office of Health Facility Licensure and Certification (OHFLAC) Abuse Reporting Memorandum (2001) directs: ""Reporting requirements: a facility must immediately report all allegations of mistreatment, neglect, abuse or misappropriation of resident property, made by a resident or any person acting on behalf of a resident to the administrator of the facility in accordance with State law through established procedures (including to the State survey and certification agency). ..."" - 2. Further review of the resident concern forms found a record of a complaint voiced by Resident #132 to a nursing staff member on 08/20/11, stating: ""Resident stated CNA was putting her to bed and bumped her leg on the bed and threw her onto the bed."" The resolution to this concern was: ""Witness statement obtained from CNA."" Further review of the facility's documentation related to this concern revealed a statement signed by Resident #132 stating: ""Asked & asked them to put me to bed messed all over myself. The big tall girl came in asked her to lay me up on the bed. She just picked me up and threw me."" - Review of the nursing notes, dated 08/19/11 at 8:30 p.m., revealed: ""Resident c/o (complained of) aid (sic) bumping her leg on bed. 4 x 3 1/2 cm (centimeter) hematoma noted. New NA (nursing assistant) assigned per res. (resident) request, ice applied to area. Scheduled pain med. given. Dr. (name of physician) on call and (name of medical power of attorney) notified."" The facility also completed an incident / accident report on 08/19/11. - The ""Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities"" (revised November 2009) requires facilities to report as follows: ""Alleged Perpetrator is a NURSE AIDE whose identity is known -> Report to Nurse Aide Program."" - When the administrator and DON were interviewed on the morning of 09/21/11, the administrator stated the facility had investigated the allegation but did not report it to State officials, because they did not substantiate abuse or neglect. -- b) Resident #157 review of the resident concern forms found a record of a complaint voiced by Resident #157 dated 07/01/11, stating: ""Resident stated she put cream on groin, I asked her to put more cream on me my hips and my private. She stated I don't have any more cream. I told her there was some in drawer. She stated if you don't like it here, you can go somewhere else."" The resolution to the resident concern was: ""Explained to resident that CNA could not put [MEDICATION NAME] cream on him, the nurse had to. The staff makes frequent rounds to check on him. I observed frequent rounds by staff, resident stated it was misunderstanding."" Further review of the facility's documentation related to this concern revealed a statement from Employee #46 (a registered nurse - RN) dated 07/02/11, stating: ""This is my statement regarding concern from (Resident #157). I leave a written report every am (morning) that discussed this situation. Apparently, no one read it. (Name of certified nursing assistant) was the CNA involved. She came to me the morning this happened and told me that he had asked for more cream on his buttocks and she told him she didn't have anymore. She said he fussed at her until she admitted saying, 'If you don't like it here, go to another facility.' When she told me that she had said that, I educated her right then that: #1 we can't say that to our residents #2 never say it again #3 if she did say it, there was a chance she could be fired. I told her she needed to go to (Resident #157's) room & apologize & ask him if he would like to talk to the nurse supervisor. She went in the room and he didn't want to speak with me. I continued on my way to Station I. When this occurred, I was concerned if (Resident #157) was fussing. That is unlike him. I suggested a U/A (uranalysis) but I reinforced to (name of CNA) that this was unacceptable to say things like this to any of our residents, even if they are rude."" - When the administrator and DON were interviewed on the morning of 09/21/11, the administrator stated the allegation had been investigated, but it was not reported to any State officials. .",2015-01-01
10613,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,226,E,1,0,W01Y11,". Based on family interview, review of the facility's abuse policies and procedures, review of in-service records, and staff interview, the facility failed to operationalize their policies and procedures regarding training of staff on the facility's process on how and to whom concerns were to be reported. This was one of the aspects of the facility's training regarding actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property. This practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings include: a) On the morning of 09/13/11, a family member (who requested anonymity) mentioned she was not certain her concerns were recorded and addressed by the facility. - Review of the facility's policy entitled ""Abuse Prohibition"" revealed process #4, ""Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include:"" ""4.1 providing customers, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed."" - Interview with the social worker (Employee #47), at 11:00 a.m. on 09/14/11, revealed the facility had recently held in-services for staff on the use of the grievance / complaint forms. Employee #47 stated all employees were required to attend. - Review of attendance records revealed no evidence thirty-seven (37) of seventy-eight (78) facility employees attended this required in-service. - The facility had not operationalized its policy to assure training for all employees in the process to assure all grievances and concerns were were documented, provided to appropriate personnel, and addressed by the facility. .",2015-01-01
10614,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,243,E,1,0,W01Y11,". Based on review of the facility's resident council meeting minutes and staff interview, the facility failed to assure the written concerns expressed by residents at their resident council meetings were acted upon. Residents expressed the same concern regarding soiled linens left on the floor during the past four (4) resident council meetings. This practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings include: a) Review of the facility's resident council meeting minutes for 09/02/11, 08/05/11,07/08/11, and 06/02/11 revealed the residents expressed the same concern regarding soiled linens each month. Each month, the residents stated soiled linens were being left in the floor of resident rooms and bathrooms. Review of the minutes revealed no written response to this concern. Based upon the continued complaints by the residents, the situation had not been acted upon by the facility. Interview with the activity director (Employee #8), at 2:00 p.m. on 09/15/11, confirmed there was no evidence this concern had been addressed. .",2015-01-01
10615,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,309,D,1,0,W01Y11,". Based on medical record review, review of incident reports, policy review, and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was provided the necessary care and services to attain or maintain his highest practicable physical well-being. This resident had four (4) unwitnessed falls and one (1) additional fall, during which he struck his head, for which neurological assessments were not performed according to nursing standards of practice and as required by facility policy. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review and review of incident reports, on 09/15/11, revealed this resident had unwitnessed falls on 06/04/11, 06/08/11, 06/09/11 and 07/26/11. Additionally he had a fall on 08/13/11, at which time he hit his head. The facility's Falls Management policy, revised 02/28/11, directed nursing personnel to: ""Perform neurological assessment (neuro-check) for all unwitnessed falls and witnessed falls with head injury."" There was no evidence in the medical record or the incident reports that neurological evaluations were done for any of these falls. Interview with the facility's director of nursing (DON - Employee #93), at 2:00 p.m. on 09/15/11, confirmed there should have been neuro-checks initiated and continued for each of these five (5) falls. The DON reviewed available facility records and reported, at 3:00 p.m. on 09/15/11, the neuro-checks had not been completed after any of this resident's falls. .",2015-01-01
10616,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,312,D,1,0,W01Y11,". Based on observation, medical record review, and staff interview, the facility failed to assure two (2) of eight (8) sampled residents, who were dependent on staff for assistance with eating, were provided services to maintain good nutrition. These residents were unable to independently feed themselves, yet were not provided assistance from nursing staff to assure adequate intake. Resident identifiers: #17 and #55. Facility census: 66. Findings include: a) Resident #17 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. A licensed practical nurse (LPN) entered the room at 8:30 a.m. to assist her roommate. The LPN did not awaken Resident #17 and/or attempt to assist her with her meal. The hallway outside Resident #17's room was observed continuously from 7:45 a.m. to 8:35 a.m., and staff was not observed making any attempt to assist this resident or awaken this resident between 7:45 a.m. and 8:35 a.m. At 8:35 a.m., the resident had not touched her meal. No one checked on the resident during the entire meal time to determine if she needed assistance, and she was not provided assistance in eating her meal. This resident's care plan, when reviewed, disclosed the following problem: ""Resident is a nutritional risk due to resident with slow wt (weight) loss trend."" There was a goal for the resident to consume 75% of her meals. One (1) of the interventions for this goal was: ""Monitor for changes in nutritional status (changes in intake, ability to feed self..."" This care plan was not implemented at breakfast on 09/14/11. -- b) Resident #55 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. The hallway outside of her room was observed continuously from 7:45 a.m. to 8:35 a.m. Staff was not observed making any attempt to awaken this resident or assist the resident between 7:45 a.m. and 8:35 a.m. At 8:35 a.m., the resident had not touched her meal. No one checked on the resident during the entire meal time to determine if she needed assistance, and she was not provided assistance in eating her meal. This resident's care plan was reviewed. The Kardex, which contained care plan information for the nursing assistants use when rendering care to Resident #55, had the following intervention: ""Encourage resident to consume all fluids / food offered during meals..."" This care plan was not implemented at breakfast on 09/14/11. -- c) Throughout the observation on 09/14/11 between 7:45 a.m. and 8:35 a.m., numerous facility staff members passed by each of these residents' rooms. This included registered nurses, licensed practical nurses, nursing assistants, administrative personnel, office personnel, activity personnel, and housekeepers. None of these facility staff members stopped to assist and/or awaken these residents. -- d) Interview with the director of nursing (DON - Employee #93), the administrator (Employee #1), and a corporate registered nurse (Employee #92), at 10:00 a.m. on 09/14/11, revealed all facility staff was responsible for assuring residents were fed at meal times. .",2015-01-01
10617,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,368,F,1,0,W01Y11,". Based on review of the facility's planned meal times and staff interview, the facility failed to assure there were no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. This was not a plan agreed to by the resident council when a nourishing snack was provided at bedtime. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 66. Findings include: a) Review of the facility's planned meal times revealed there were fourteen and one-half (14-1/2) hours between a substantial evening meal and breakfast the following day. When this was brought to the attention of the administrator (Employee #1) at 10:00 a.m. on 09/14/11, Employee #1 reviewed the times and confirmed there was one-half (1/2) hour more time between these meals than allowed by this regulation. .",2015-01-01
10618,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,241,E,1,0,W01Y11,". Based on observation and staff interview, the facility failed to promote dignity for four (4) of eight (8) sampled residents during mealtime. Residents were placed outside the 100 hallway dining area for up to an hour waiting for their breakfast. These four (4) residents were able to view other residents being fed while they waited for their meal. Additionally, after being taken into the dining area, two (2) of these four (4) residents were not served at the same time as other residents in the room. This resulted in them watching other residents being fed while still not receiving their meal. Resident identifiers: #1, #3, #12, and #66. Facility census: 66. Findings include: a) Residents #1 and #3 At 7:15 a.m. on 09/14/11, Residents #1 and #3 were observed outside the 100 hallway dining area. At this time, the residents were watching other residents being served breakfast and they had not been served their breakfast. An hour passed before these residents were taken into the dining area at 8:15 a.m. After the residents were taken into the dining room, they sat for an additional ten (10) minutes before being served their breakfast at 8:25 a.m. These residents sat for a total of one (1) hour and ten (10) minutes watching other residents eating breakfast before being provided their meals. -- b) Resident #12 On 09/14/11 at 7:15 a.m., Resident #12 was observed outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 8:00 a.m. This resident sat for forty-five (45) minutes watching other residents eating before she was served her breakfast. -- c) Resident #66 On 09/14/11 at 7:15 a.m., Resident #66 was observed sitting outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 7:40 a.m. For twenty-five (25) minutes, this resident sat watching other residents eating before she was served her breakfast. When the staff placed the tray on the table, the resident immediately grabbed her spoon and rapidly began to eat her cereal. .",2015-01-01
10619,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,353,F,1,0,W01Y11,". Based on observation, staff interview, confidential family interview, and review of resident council meeting minutes, the facility failed to deploy and supervise staff in a manner which assured the provision of assistance residents required for six (6) of twelve (12) sample residents and one (1) resident randomly identified during the survey. Residents were not provided assistance with meals in a timely manner, were not assisted in getting dressed in time to go to the dining room, and meals were not offered in the dining room due to staffing. Additionally, the resident council minutes revealed the lack of availability of staff had an impact on their lives in the facility. This practice affected seven (7) residents during the survey, but it had the potential to affect all facility residents. Resident identifiers: #1, #3, #12, #21, #66, #55, and #17. Facility census: 66. Findings include: a) Residents #1 and #3 At 7:15 a.m. on 09/14/11, Residents #1 and #3 were observed outside the 100 hallway dining area. At this time, the residents were watching other residents being served breakfast and they had not been served their breakfast. An hour passed before these residents were taken into the dining area at 8:15 a.m. After the residents were taken into the dining room, they sat for an additional ten (10) minutes before being served their breakfast at 8:25 a.m. These residents sat for a total of one (1) hour and ten (10) minutes watching other residents eating breakfast before being provided their meals. -- b) Resident #12 On 09/14/11 at 7:15 a.m., Resident #12 was observed outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 8:00 a.m. This resident sat for forty-five (45) minutes watching other residents eating before she was served her breakfast. -- c) Resident #66 On 09/14/11 at 7:15 a.m., Resident #66 was observed sitting outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 7:40 a.m. For twenty-five (25) minutes, this resident sat watching other residents eating before she was served her breakfast. When the staff placed the tray on the table, the resident immediately grabbed her spoon and rapidly began to eat her cereal. -- d) Residents #17 and #55 1. Resident #17 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. A licensed practical nurse (LPN) entered the room at 8:30 a.m. to assist her roommate. The LPN did not awaken Resident #17 and/or attempt to assist her with her meal. The hallway outside Resident #17's room was observed continuously from 7:45 a.m. to 8:35 a.m., and staff was not observed making any attempt to assist this resident or awaken this resident between 7:45 a.m. and 8:35 a.m. At 8:35 a.m., the resident had not touched her meal. No one checked on the resident during the entire meal time to determine if she needed assistance, and she was not provided assistance in eating her meal. This resident's care plan, when reviewed, disclosed the following problem: ""Resident is a nutritional risk due to resident with slow wt (weight) loss trend."" There was a goal for the resident to consume 75% of her meals. One (1) of the interventions for this goal was: ""Monitor for changes in nutritional status (changes in intake, ability to feed self..."" This care plan was not implemented at breakfast on 09/14/11. - 2. Resident #55 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. The hallway outside of her room was observed continuously from 7:45 a.m. to 8:35 a.m. Staff was not observed making any attempt to awaken this resident or assist the resident between 7:45 a.m. and 8:35 a.m. At 8:35 a.m., the resident had not touched her meal. No one checked on the resident during the entire meal time to determine if she needed assistance, and she was not provided assistance in eating her meal. This resident's care plan was reviewed. The Kardex, which contained care plan information for the nursing assistants use when rendering care to Resident #55, had the following intervention: ""Encourage resident to consume all fluids / food offered during meals..."" This care plan was not implemented at breakfast on 09/14/11. - 3. Throughout the observation on 09/14/11 between 7:45 a.m. and 8:35 a.m., numerous facility staff members passed by each of these residents' rooms. This included registered nurses, licensed practical nurses, nursing assistants, administrative personnel, office personnel, activity personnel, and housekeepers. None of these facility staff members stopped to assist and/or awaken these residents. - 4. Interview with the director of nursing (DON - Employee #93), the administrator (Employee #1), and a corporate registered nurse (Employee #92), at 10:00 a.m. on 09/14/11, revealed all facility staff was responsible for assuring residents were fed at meal times. -- e) Resident #21 This resident was observed still in bed at 8:00 a.m. on 09/14/11. At 8:10 a.m., a nursing assistant came to the resident's room and asked her if she was going to the dining room for breakfast. The resident stated she had not been gotten up to get dressed, so she would not be able to go to the dining room. -- f) Review of the facility's resident council meeting minutes, dated 09/02/11, revealed the following quote as written by the staff member who took the minutes for the residents on that date: ""Residents expressed concerns relating to departments being short staffed when someone in nursing calls in and there is no one to fill that person's shift. Residents feel they really are the ones who feel the impact the most and feel that managers need to make sure the departments run as if there was staff."" -- g) During an interview on 09/13/11 at 2:40 p.m., a family member (who wished to remain anonymous) expressed concern that residents were often not taken to the dining room, but were fed in their rooms, due to staffing issues. An interview was conducted with the DON on 09/14/11 at 10:00 a.m., regarding this family member's concern. The DON reported that feeding residents in their rooms did not save staff time, stating, ""They only think it does."" .",2015-01-01
10620,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2011-09-16,225,D,1,0,W01Y11,". Based on review of the facility's incident reports and staff interview, the facility failed to investigate and report an unwitnessed and unexplained bruise for one (1) of twelve (12) sample residents. Resident #12 had a bruise on her right breast with no indication the facility had reported this injury of unknown origin or conducted an investigation to rule out potential abuse and/or neglect. Resident identifier: #12. Facility census: 66. Findings include: a) Resident #12 On 09/14/11, the facility's incident reports from March through September 2011 were reviewed for reports of injuries of unknown origin. This review revealed a bruise was identified on the right breast of Resident #12 at 5:30 p.m. on 07/17/11. The bruising was described as purple, green, and yellow in color by a registered professional nurse (RN - Employee #73). Upon inquiry by staff at that time, the resident stated she did not know how this bruise happened. On 09/15/11 at approximately 10:00 a.m., the director of nursing (DON - Employee #93) was asked to provide evidence to reflect this injury of unknown origin had been immediately reported (to State agencies as required by law) and thoroughly investigated. At 4:15 p.m. on 09/15/11, the DON reported there was no evidence the facility had reported or investigated the bruising found on this resident. She stated, ""I don't know why it wasn't reported."" .",2015-01-01
10621,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,156,D,0,1,GCMN11,". Based on record review and staff interview, the facility failed, for one (1) of two (2) applicable residents / responsible parties, to provide notice of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. Resident identifier: #3. Facility census: 83. Findings include: a) Resident #3 During the morning of 12/08/10, records were reviewed for three (3) residents whose Medicare-covered services had been discontinued by the facility. At the same time, interviews were conducted with facility corporate office personnel who were assisting with bookkeeping responsibilities in the absence of the facility's bookkeeper. Record review revealed Resident #3's Medicare-covered services were discontinued on 09/16/10, because he had reached his maximum potential in occupational therapy services. The corporate persons were unable to locate evidence Resident #3 received a notice his Medicare services were discontinued, and no evidence the resident / responsibility party had been given the opportunity to request a demand bill. On 12/09/10, the facility's bookkeeper (Employee #18) searched her records for evidence that the appropriate notices had been given to Resident #3. During the morning of 12/09/10, Employee #18 reported the ""cut letter"" and opportunity to request a demand had not been provided this resident / responsible party. .",2015-01-01
10622,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,159,B,0,1,GCMN11,". Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. .",2015-01-01
10623,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,167,C,0,1,GCMN11,". Based on observation and staff interview, the facility failed to assure the facility's survey results were posted in an area that was accessible to all residents. The results that were in the posting did not include the deficiencies cited during complaint investigations that were conducted since the facility's last standard annual survey. This practice had the potential to affect all residents who desire to review the facilities survey results. Facility census: 83. Findings include: a) Observation of the facility's publicly posted information, on the morning of 12/01/10, found the facility's survey results were posted between the two (2) front double doors in an area where most of the residents were not permitted. Review of the survey results that were posted found they did not contain the results of complaint investigations that had been conducted since the facility's last standard annual survey, during which the facility was cited deficiencies. The administrator was notified of this finding at 12:45 p.m. on 12/08/10. She verified the survey results that were posted were not complete and were not posted in an area that was accessible to all residents. .",2015-01-01
10624,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,241,D,0,1,GCMN11,". Based on observation, the facility failed to ensure one (1) of eighteen (18) residents seated in the dining room for the evening meal on 11/29/10 was treated in a dignified or respectful manner as he waited for his meal. The resident was ignored by staff when he asked for assistance with drinking the orange beverage which had been placed in front of him. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 On 11/29/10 at 5:05 p.m., this resident was seated in the dining room when a refreshment cart was brought to the room by staff members. An orange beverage was placed in front of the resident. The resident was unable to grasp or drink the beverage without assistance, and he requested assistance with drinking from staff. Four (4) different staff members passed by the resident and failed to acknowledge the resident or his request. The fifth time the resident asked for a drink, a nurse stopped and told the resident he could not have his beverage until his special cup came out on his tray. On the resident's sixth request to get a drink, another staff member stopped what she was doing, acknowledged the resident's request, and assisted him in drinking the beverage. It should be noted that the resident's tray, with the special cup, was not served the resident until after 5:30 p.m. .",2015-01-01
10625,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,242,D,0,1,GCMN11,". Based on resident interview, medical record review, and staff interview, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents was provided showers as she desired, on her scheduled shower days. Resident identifier: #32. Facility census: 83. Findings include: a) Resident #32 During Stage I resident interviews on 11/30/10 at 3:29 p.m., this resident described she was not receiving her showers as scheduled. The resident stated she was scheduled for showers on Mondays and Thursdays, but these showers were not always provided by staff. Further interview revealed the showers were not provided on other days, if they happened to be missed on Mondays and Thursdays. The resident's choice was for her showers to be provided twice weekly and on Mondays and Thursdays as scheduled. On 12/06/10 at 4:45 p.m., this resident's nursing assistant flow sheets were reviewed. As stated by the resident, she was scheduled for showers on Mondays and Thursdays on the 3-11 shift. Review of the October, November, and December 2010 records revealed the resident was not provided showers on the following Mondays: 10/04/10, 11/08/10, and 11/25/10. Additionally, she was not provided showers on the following Thursdays: 11/11/10, 11/25/10, and 12/02/10. (There was one (1) refusal on a scheduled shower day in October, and this day was not counted in the assessment of showers provided.) This information was brought to the attention of the director of nursing (DON). During the morning of 12/09/10, the DON reported she was unable to locate any information which disputed the showers had not been given as scheduled. .",2015-01-01
10626,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,244,E,0,1,GCMN11,". Based on a review of the resident council meeting minutes and staff interview, the facility failed to assure requests made by residents during the monthly resident council meeting were acted upon. During the October 2010 resident council meeting, the residents asked to have copies of the meal menus posted in their rooms. No action was taken to comply with this request as of 12/09/10. This practice has the potential to affect more than an isolated number of residents. Facility census: 83. Findings include: a) According to the October 2010 resident council meeting minutes, the residents in attendance verbalized that they would like to have menus of the meals posted in their rooms. The response from the facility's dietary department was that they would post them as soon as the menus changed. As of the 12/09/10, the menus were still not posted in the residents' rooms, and there was no further response to the council members' request. .",2015-01-01
10627,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,253,D,0,1,GCMN11,". Based on observation and staff interview, the facility failed to provide maintenance services to maintain a comfortable interior for the residents. Observation found the corridors to rooms #153 and #101 were not properly functioning and would not remain open, and the corridor door to room #158 had scratched / splintered pealing wood on the door. This practice affected three (3) of thirty-two (32) doors to residents' rooms. Facility census: #83. Findings include: a) Room #153 Observation found the corridor door to this room was closed on multiple occasions throughout the first week of the survey. When observed at 10:00 a.m. on 12/08/10, the door was propped open with a trash can. When the trash can was moved, the door automatically went shut on its own and would not remain open. b) Room #101 Observation found the corridor door to this room was propped open with a trash can on 12/08/10. When the trash can was moved by this surveyor, the door would not remain open but, instead, closed on its own. c) Room #158 Observation found the corridor door to this room had peeling wood that was splintered on the edges of the door. d) Employee #22 (the maintenance supervisor) was made aware of the issues with these three (3) doors at 1:00 p.m. on 12/09/10. He verified the doors were in need of repair at that time and stated he would address them. .",2015-01-01
10628,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,272,D,0,1,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to assess one (1) of thirty-two (32) Stage II sample residents for his continued need for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During the evening meal observation on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed no coughing, choking, or strangling as the resident drank the beverage. At that time, it was not known that the resident had a physician's orders [REDACTED]. On 12/07/10, review of the resident's medical record found a physician's orders [REDACTED]. There was a speech therapy assessment, dated 11/11/09, which indicated a need for honey thick liquids. There was no evidence of a more current speech therapy assessment. Additionally, on 03/18/10, the facility had a ""hold harmless"" form completed by the appropriate representative, so the resident could drink regular ""Coca Cola"". On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). After hearing the resident drank thin liquids without evidence of a problem on 11/29/10, the DON confirmed a new speech therapy evaluation was indicated. .",2015-01-01
10629,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,280,D,0,1,GCMN11,"**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 Resident #115's plan of care to reflect the diet that was being provided by the facility. The resident had dietary restrictions ordered by her physician and included in her care plan that restricted the use of added salt. Observation found she received a package of salt on her meal tray, and staff added the salt to her food. The facility did not assure the resident's care plan was revised to include the resident's wishes and refusal to eat meals without salt. This was observed for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. Employee #94, when interviewed regarding the salt, she said this resident will not eat food without adding salt. ""If you do not salt it, she will send you after the salt before she will eat the food."" She stated they started just sending it on her tray, because staff would have to go get it anyway. The medical record was reviewed again, and there was no evidence that the resident's non-compliance with her no added salt diet had been recorded and addressed with the physician. The director of nursing (DON), when interviewed on the afternoon of 12/02/10 regarding this resident's diet, verified that, according to the physician's orders [REDACTED]. She agreed the care plan should have been revised to address the resident's non-compliance with her diet instead of just going ahead and sending her salt. .",2015-01-01
10630,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,282,D,0,1,GCMN11,". Based on observation, medical record review, and staff interview, the facility failed to implement the current care plan for one (1) of thirty-two (32) Stage II sample residents. The facility did not implement the resident's care plan for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During observation of a pre-meal activity prior to the evening meal on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed a nursing staff member assisted the resident in drinking this beverage. On 12/07/10, the resident's medical record was reviewed. The resident had current care plan approaches to ""Provide honey thickened liquids"" and ""Encourage resident to drink thickened liquids only."" The resident was provided the thin liquids at his table on 11/29/10. When assisting the resident to drink the beverage, nursing staff did not mention to the resident that the beverage was not thickened and/or provide the resident with a beverage of the proper consistency. On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). At that time, the DON confirmed the care plan should have been followed and the resident should have had thickened liquids at the pre-meal activity. .",2015-01-01
10631,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,309,D,0,1,GCMN11,". Based on medical record review, review of the facility's bowel protocol, and staff interview, the facility failed to implement its bowel protocol for one (1) of thirty-two (32) Stage II sample residents. Additionally, the facility failed to assure this resident, who had serious problems with constipation, had an individually written bowel protocol. The facility's protocol called for interventions beginning when a resident did not have a bowel movement (BM) in three (3) days. This resident was not provided interventions until nine (9) days when indicated on one (1) occasion and six (6) days when indicated on another occasion. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 Medical record review, on 12/07/10, revealed a nursing note dated 10/06/10 at 7:10 a.m., which stated, ""Resident given enema d/t (due to) (symbol for 'no') BM's (bowel movements) charted for 9 days."" Continued review of the record, including the medication administration records (MARs) and BM records revealed no interventions prior to the enema, which was given after nine (9) consecutive days with no BM. Another nursing note, on 11/10/10 at 10:00 p.m., stated, ""Resident on day 6 of BM (without a bowel movement for 6 days). MOM (milk of magnesia) given..."" Continued review of the record, including the MARs and BM records, revealed no interventions prior to the MOM which was given after six (6) consecutive days with no BM. The facility had standing orders, which were called ""Routine Protocol"" with a revision date of November 2006. A copy of this protocol was in the resident's medical record. This routine protocol contained a protocol for constipation, which stated: ""The BM record should be checked daily on 3-11 shifts. If a resident has not had a BM in 3 days, give MOM 30 cc PO (by mouth) at H.S. (bedtime). On the third day force fluids unless contraindicated, at least 2000 cc/24 hours. If no results from MOM administration, then the next morning of the fourth day 7-3 shift the resident needs to be checked for presence of hard / soft stool in the rectum and removed. Then follow up with a Fleets enema. May give Fleets enema 1 per rectum prn (as needed) for constipation not to exceed 1 in 24 hours. If no result contact physician."" Prior to the enema on 10/06/10, there was no evidence the resident's BM records were checked daily on the 3-11 shift, to implement the routine protocol for constipation. The protocol was not implemented by first providing MOM after the third day without a BM. There was no evidence the resident was ""checked for presence of hard / soft stool in the rectum and removed"" on the fourth day, as directed in the protocol. There was no evidence of any intervention until Day 9, when an enema was given. Had the protocol been implemented and the resident remained without a BM, the Fleets enema should have been given on Day 4. Prior to the MOM on 11/10/10, there was no evidence the resident's BM records were checked daily on the 3-11 shift, to implement the routine protocol for constipation. The protocol was not implemented by first providing MOM after the third day without a BM. In this instance, the MOM was not provided until Day 6. There was no evidence the resident was ""checked for presence of hard / soft stool in the rectum and removed"" on the fourth day, according to the protocol. There was no evidence of any intervention until Day 6, when MOM, which should have been given on Day 3, was given. At 2:30 p.m. on 12/07/10, the resident's medical records were reviewed with the director of nursing (DON). The DON was unable to find any evidence that the protocol for constipation had been implemented for this resident in October or November 2010. At that time, the DON stated this resident needed an individually written bowel protocol. .",2015-01-01
10632,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,312,D,0,1,GCMN11,". Based on family interview, resident interview, staff interview, and observation, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents received necessary services to maintain good personal hygiene. This resident, who was unable to perform her own activities of daily living, had dry, flaky feet and long, jagged, dirty fingernails. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During this interview, 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 a registered nurse (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. During this observation, the resident's fingernails were noted to be long, jagged, and dirty. The resident's care plan indicated the resident liked long fingernails. Upon inquiry, the resident confirmed she liked long fingernails, but she looked at her nails and stated, ""Not this long. They need trimmed."" .",2015-01-01
10633,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,323,E,0,1,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to maintain an environment free of accident hazards for two (2) of thirty-two (32) Stage sample residents. Resident #90 was observed on several occasions wearing socks without non-skid soles, when he was care planned to wear non-skid sole shoes. Resident #10 was observed drinking thinned liquids, when he was ordered thickened liquids. Also, on the East Wing in the shower room, a shower chair was found sitting in the corner with rusted wheels that were in poor condition. This shower chair, which was available for use, presented an accident hazard to more than an isolated number of residents. Resident identifiers: #90 and #10. Facility census: 83. Findings include: a) Resident #90 On 11/29/10 at 3:50 p.m., the resident was observed in the activities room, propelling himself in wheelchair and wearing white socks without non-skid soles. The resident was again observed propelling himself in wheelchair on 11/30/10 at 2:00 p.m., wearing white socks without non-skid soles. On 12/01/10, 12/02/10, 12/06/10, 12/07/10, and 12/08/10, the resident was observed propelling himself in wheelchair wearing white socks with non-skid soles. Review of the resident's care plan revealed he was to wear non-skid sole shoes due to risk of falls. An interview with a licensed practical nurse (LPN - Employee #5) revealed the resident was capable of transferring himself without assistance from the bed to the wheelchair, and he also ambulated to the restroom occasionally without assistance. On 12/08/10 at 1:30 p.m., an interview with registered nurse (RN - Employee #70) revealed she was unaware if the resident had a pair of non-skid sole shoes, but she would put some non-skid socks on the resident. An observation, on 12/08/10 at 4:00 p.m., found the resident was wearing non-skid socks while propelling himself down the hallway. b) Resident #10 During observation of a pre-meal activity prior to the evening meal on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed a nursing staff member assisted the resident in drinking this beverage. On 12/07/10, the resident's medical record was reviewed. The resident had current care plan approaches to ""Provide honey thickened liquids"" and ""Encourage resident to drink thickened liquids only."" In addition, the resident had a physician's orders [REDACTED]."" The resident was provided the thin liquids at his table on 11/29/10, and was assisted by nursing staff to drink the beverage which was not thickened. This created an accident hazard for the resident. On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). At that time, the DON confirmed the physician's orders [REDACTED]. c) Shower Room During a tour of the environment on 12/07/10, observation of the shower room on the East end of the facility found a shower chair sitting in the corner of the room by the bathtub with boxes sitting on top of it. All four (4) wheels on this shower chair was rusted, and when this surveyor went to move the chair, the wheels did not move freely. A nursing assistant (Employee #10), when questioned about the shower chair at 2:00 p.m., stated she had never known of anyone using that shower chair since she has worked there, and she did not know why this chair was sitting in the room. She was made aware this could be an accident hazard if someone were to use this chair, because the wheels did not freely move. She agreed and stated that she would have the chair removed. .",2015-01-01
10634,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,325,D,0,1,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure feeding recommendations made by the speech-language pathologist (SLP) for Resident #115 were implemented as written. The facility also failed to assure the diet ordered by the physician was followed and that the physician was notified when the resident was non-compliant with the diet, to see if the diet order could be changed. This resident had a history of [REDACTED]. This practice affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Further review of the record found a speech therapy evaluation and recommendations made by the SLP 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. Further review of the medical record revealed that, when the resident was admitted to the facility on [DATE], her weight was 103#. Her weight on 09/01/10 was 116#. The resident's weight on 10/01/10 was 113#. The resident's weight on 11/15/10 was 107#. This represented a weight loss of 9# in two (2) months and 6# in one (1) month. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. She had a straw in her milk, and Employee #94 fed her without giving verbal cueing or alternating the food with drinks after two (2) to three (3) bites, as recommended by the SLP. Employee #94, when interviewed regarding the salt, she said this resident will not eat food without adding salt. ""If you do not salt it, she will send you after the salt before she will eat the food."" She stated they started just sending it on her tray, because staff would have to go get it anyway. When questioned about the resident's use of straws in her beverages, she said the the resident was not able to drink from the plastic milk jugs without straws. The medical record was reviewed again, and there was no evidence that the resident's non-compliance with her no added salt diet had been recorded and addressed with the physician or that it had been reported that this resident would not drink without a straw. The director of nursing (DON), when interviewed on the afternoon of 12/02/10 regarding this resident's diet, verified that, according to the physician's orders [REDACTED]. She agreed the care plan should have been revised to address the resident's noncompliance with her diet instead of just going ahead and sending her salt. She also agreed that the resident's milk could have been poured into a glass, so that the resident could drink it without a straw as recommended by the SLP. .",2015-01-01
10635,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,332,D,0,1,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, review of the facility's drug handbook, and staff interview, the facility failed to ensure that it was free of medication error rates of five percent (5%) or greater. Out of fifty-one (51) medication opportunities, there were three (3) errors observed. This resulted in an error rate of five and eighty-eight-one hundredths percent (5.88%). This practice effected three (3) of ten (10) residents. Resident identifiers: #50, #43, and #42. Facility census: 83. Findings include: a) Resident #50 During medication pass on 12/06/10 at 1:50 p.m., a registered nurse (RN - Employee #75) was observed to administer eye drops to Resident #50. The physician's orders [REDACTED]. Employee #75 was observed to administer one (1) gtt (drop) to both eyes. When questioned about the eye drops and why they were administered to both eyes, Employee #75 stated this was how the resident wanted it. She agreed the physician needed to be contacted to have the order changed. -- b) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler ""[MEDICATION NAME] Diskus 1 (one) puff"" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the [MEDICATION NAME] Diskus. It was noted that the [MEDICATION NAME] was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book for the proper use of the [MEDICATION NAME] Discus. During an interview with the facility's consultant pharmacist on the afternoon of 12/07/10, she was asked about the correct way to administer the [MEDICATION NAME] Discus. She verified it was recommended by the manufacturer that the user rinse and spit, so the medication does not go down the esophagus and into the stomach. She was made aware that the facility did not have the directions available for the correct use of this medication. -- c) Resident #42 During medication pass on 12/07/10 at 10:30 a.m., the RN (Employee #48) administered to Resident #42 ""Senna two (2) tabs by mouth"". After this medication was administered, review of the physician's orders [REDACTED]."" When questioned about this medication on 12/07/10 at 10:35 a.m., the RN stated she did not give the ""Senna Plus"", because the resident did not want to take the ""plus"". She stated the resident wanted the regular Senna. There was no evidence the physician had been notified that the facility was not administering this medication as ordered. .",2015-01-01
10636,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,353,F,0,1,GCMN11,". Based on review of the facility's nursing schedules and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each shift. According to facility staff, nursing employees ""know"" who the charge nurse is, but this person is not designated as required by this regulation. This practice has the potential to affect all facility residents. Facility census: 83. Findings include: a) Review of the facility's nursing schedules revealed a licensed nurse was not designated to serve as the charge nurse on each shift. The staff development coordinator (Employee #109) stated, at 9:30 a.m. on 12/07/10, the facility has ""never designated a person in charge, they just know."" .",2015-01-01
10637,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,356,C,0,1,GCMN11,". Based on observation and staff interview, the facility failed to assure the required information regarding nursing staffing was posted at the beginning of each shift. The census and/or the hours actually worked were not posted in a clear and readable format. Seventeen (17) days was reviewed, and there were twenty (20) shifts for which no information was available on these postings. This information is provided so residents and the public can review the facility's staffing patterns at any given time. The practice of not posting complete and accurate information has the potential to affect all residents and visitors who would like to review the staffing. Facility census: 83. Findings include: a) Observation of the facility's posting of nurse staffing data, on 12/08/10 at 10:30 a.m., found it did not contain the hours actually being worked at that time. The posting is required to be updated at the beginning of each shift; therefore, this posting should have been completed at 7:00 a.m. Further review of the facility's nurse staffing data sheets found there were twenty (20) shifts in the last seventeen (17) days that had not been posted. The staffing sheets did not record the census at the beginning of each shift and the actual hours worked by the nursing staff responsible for care per shift. The registered nurse supervisor (Employee #20) was made aware that the posting was not being completed as required. .",2015-01-01
10638,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,371,F,0,1,GCMN12,". Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) During observation of the dietary department with the dietary manager (DM - Employee #63) on 02/22/11 at 3:15 p.m., the following sanitation infractions were identified: 1. The drain of the handwashing sink was too slow to drain quickly enough to prevent hands from coming in contact with the water as hands were being washed. 2. There was no waste receptacle, which was touch free, at the handwashing sink to dispose of paper towels after washing hands. 3. The large blue soup / cereal bowls contained debris which could be scraped off with a fingernail. When observed, the DM took a bowl into the dish room and used a non-scratch abrasive sponge on a bowl. The debris was removed by this method. 4. Clear beverage containers were not air dried prior to lids being placed on them and lids for the pellet system were stacked with moisture between them. The trapped moisture in these items created a potential for bacterial growth. 5. Clean plates were placed in the plate warmer prior to cleaning crumbs and debris from the warmer. 6. The underneath of the clean silverware rack contained a greasy / dusty debris which was able to be removed upon touch. The facility's food handler gloves were stored under this silverware rack. -- b) On 02/24/11 at 1:00 p.m., a dietary employee (#92) was observed serving a meal. He touched his face around his nose and mouth with his gloved hand, then immediately resumed serving food without changing his gloves and washing his hands. -- c) On 03/02/11 at 12:55 p.m., a meal tray, which was tested for temperatures in the presence of the DM, revealed the coleslaw was 51.4 degrees Fahrenheit (F). This particular tray had left the kitchen only a few minutes prior to testing. At 1:15 p.m., the temperature of cold foods was measured, with the DM, on another test tray. The coleslaw on this tray 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. To prevent food borne illnesses, cold foods must be chilled by a means to assure the middle of the foods are quickly cooled to 40 degrees F. .",2015-01-01
10639,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,425,D,0,1,GCMN11,". Based on observation, review of the facility's drug reference handbook, and staff interview, the facility failed to assure the pharmaceutical services provided to residents included assuring that staff had the proper instructions available for administering medications ordered by the physician. There were no instructions available in the facility to instruct the nurse of the proper administration of Advair Diskus. The medication did not come from the pharmacy in its original container, and there were no manufacturer's instructions available and no instructions in the facility's drug reference handbook. The nurse instructed the resident to take a drink instead of instructing the resident to rinse her mouth following the administration of the Advair Diskus inhaler. This affected one (1) of one (1) resident observed to receive this type of inhaler. Resident identifier: #43. Facility census: 83. Findings include: a) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler ""Advair Diskus 1 (one) puff"" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the Advair Diskus. It was noted that the Advair was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book for the proper use of the Advair Discus. During an interview with the facility's consultant pharmacist on the afternoon of 12/07/10, she was asked about the correct way to administer the Advair Discus. She verified it was recommended by the manufacturer that the user rinse and spit, so the medication does not go down the esophagus and into the stomach. She was made aware that the facility did not have the directions available for the correct use of this medication. .",2015-01-01
10640,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,431,E,0,1,GCMN11,". Based on observation and staff interview, the facility failed date open medications in accordance with current standards of practice. This deficient practiced has the potential to affect more than an isolated number. Facility census: 83. Findings include: a) On 11/29/10 at 2:30 p.m., an observation was made in the East Wing medication storage room, in the company of a licensed practical nurse (LPN - Employee #5) revealed a vial of influenza vaccine with no date was found open in the medication storage refrigerator. With a date to reflect when this vial was opened, it was not possible to determine when the contents of the vial were no longer safe for use. . .",2015-01-01
10641,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,441,E,0,1,GCMN12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and policy review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help help prevent the transmission of disease and infection, by failing to immediately implement transmission-based precautions when Resident #38 returned from a hospital stay with a [DIAGNOSES REDACTED]. These practices had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of Resident #38's medical record revealed a discharge summary from a local hospital, dated 02/17/11, with a discharge [DIAGNOSES REDACTED]. Review of Resident #38's facility admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 02/18/11 at 3:00 a.m., revealed the resident remained on antibiotic therapy due to a positive Clostridium difficile culture. A nurse's note, dated 02/18/11 at 12:00 p.m., revealed the resident changed rooms due to positive Clostridium difficile with five (5) days of antibiotic therapy remaining. An interview with Employee #64, on 03/01/11, revealed Resident #38 was placed in isolation ""a little before 12:00 p.m. on 02/18/11."" Employee #64 also stated the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the facility policy regarding ""Isolation - Categories of Transmission - Based Precautions"" revealed contact precautions should be implemented ""for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ... Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g. the individual is incontinent on the floor, or wanders and touches others)."" Review of Resident #38's medical record revealed the resident was incontinent of bowel and bladder, and observation revealed she was able to ambulate in her wheelchair. For example, on 02/22/11 at 3:20 p.m. and again on 03/01/11, she was observed ambulating in her wheelchair within her room, and on 03/02/11 at 1:45 p.m., she was observed sitting in the doorway of her room in her wheelchair. -- b) On 02/23/11 at 1:50 p.m., a nursing assistant (#95) was observed passing ice on the East Hall. She was holding the pitchers, taken from residents' rooms, over the ice in the ice chest as she filled each pitcher. This practice created a potential for cross contamination. At the time of the observation, a registered nurse (Employee #105) was shown the practice and confirmed Employee #95 should not hold the pitchers over the ice while filling them. .",2015-01-01
10642,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,463,D,0,1,GCMN11,". Based on observation, resident interview, and staff interview, the facility failed to assure residents' rooms were equipped with functioning nurse call systems. Room #123 had a private bathroom that had no string on the call bell system to ring if the occupant of the room fell . This resident took her self to the bathroom and stated she had to reach up and push the button, because there was no string on her call light. This practice was found to be true for one (1) of forty (40) call lights observed. Facility census: 83. Findings include: a) During a tour of the environment on 12/10/10, observation of Room #123 found the private bathroom did not have a string on the call light. Without the string, if the resident were to fall in the bathroom, she would not be able to call for assistance. During an interview with the resident on the morning of 12/10/10, she stated she uses that call bell, but she has to reach up and push the button because there is no string. A registered nurse (RN - Employee #20) was made aware that this call light did not have a string to pull in case of an emergency at 11:30 a.m. 12/10/10. .",2015-01-01
10643,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,318,D,0,1,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM, as evidenced by the facility's failure to ensure a resident wore a splint ordered by a physician. One (1) of forty (40) residents on the Stage I sample was affected. Resident identifier: #85. Facility census: 83. Findings include: a) Resident #85 During the Stage I information gathering phase of the survey, staff reported this resident was supposed to wear a splint to her left hand. An observation, during Stage I on 11/30/10 at 3:24 p.m., revealed the resident did not have a splint in place. On 12/18/10 at 4:15 p.m., review of the resident's December 2010 physician's orders [REDACTED]."" This order originated on 05/27/10. At 10:40 a.m. on 12/09/10, an observation revealed the resident, again, did not have a splint in place. On 12/09/10 at 10:45 a.m., an interview with a registered nurse (RN - Employee #70) revealed the resident had not worn the splint for approximately one (1) week. Employee #70 stated that staff oftentimes forgot to put the splint on the resident, but if they did, the resident often took it off. Review of the resident's nursing notes revealed no entries stating that staff had attempted to place the splint on the resident's left hand. Further review of the nursing note revealed no entries stating that the resident refused to wear the splint. .",2015-01-01
10644,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,492,C,0,1,GCMN11,". Based on staff interview and review of individual food service workers' permits, the facility was not in full compliance with local laws regarding food handler's cards. One (1) of ten (10) dietary employees, who was currently working, had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 83. Findings include: a) During the survey, each dietary employee's food handler's card was reviewed. No card was available for Employee #111. The dietary manager (Employee #68) was asked to determine if Employee #111 had a current food handler's card. Employee #68 reported that Employee #111's food handler's card was expired and that she was now scheduled to renew the card. .",2015-01-01
10645,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2011-03-02,469,F,0,1,GCMN12,". Based on observation and staff interview, the facility failed to provide an effective pest control program which assured the facility was free of insects. Small black flying insects were observed in hallways and resident rooms. This practice affected two (2) of nineteen (19) sample residents and one (1) resident identified during a random opportunity for observation. The insects were also noted in the hallway of the West Hall. This situation had the potential to affect all facility residents. Resident identifiers: #16, #18, and #3. Facility census: 84. Findings include: a) Resident #3 During a random opportunity for observation, small flying black insects were observed in this resident's room at 9:30 a.m. on 02/23/11. -- b) Resident #16 During a discussion with this resident on 02/23/11 at 10:00 a.m., small flying black insects were observed in this resident's room and around her head. During the conversation, the resident was observed swatting at one (1) of the insects as it continually landed on her face. -- c) Resident #18 During an interview with this resident at 2:30 p.m. on 02/28/11, small flying black insects were observed flying around this resident's room and around her head. The resident swatted at the insects several times during the interview. -- d) At 10:00 a.m. on 03/01/11, small black flying insects were observed on the West hallway. -- e) Just prior to noon on 03/01/11, a discussion was held with the administrator (NHA - Employee #117) regarding the small flying black insects which had been observed during the survey. The NHA confirmed the existence of the insects and referred to them as ""gnats"". He stated he was aware of the problem and that the exterminator had been there ""last Friday"". At that time, it was confirmed that the problem was not resolved, as the insects remained in the facility. .",2015-01-01
10646,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2011-03-02,520,F,0,1,GCMN12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware, reflective of system failures in the areas of implementation of each resident's written plan of care, accident hazards, food preparation and appearance, dietary sanitation, infection control, and accurate and complete clinical records; and failed to develop and implement appropriate plans of action to correct these quality deficiencies. Each of these deficiencies was a repeat deficiency from previous surveys. This failure has the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) Failure to implement each resident's written plan of care: 1. During the initial tour at 3:15 p.m. on 02/22/11, Resident #41 was observed with a very red face and was coughing. Two (2) staff members (Employees #30 and #7) were in the room but did not appear to notice anything happening with the resident. Another resident's family member had to summon the employees to help the resident. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, on 02/23/11, revealed he was assessed with [REDACTED]. The resident's care plan, dated 02/14/11, contained the following goal: ""Resident will have no unidentified s/s (signs and symptoms) of aspiration through the next review 05/14/11."" One (1) of the interventions for this goal was: ""Monitor for increased incidence of choking, coughing during meals or PO (by mouth) intake, red face, watery eyes, difficulty breathing and notify MD (physician)."" On 02/22/11 at 3:15 p.m., this resident was not being monitored while eating, as directed by the care plan. - 2. Review of accident and incident reports, on 02/23/11, revealed Resident #16 spilled coffee on herself on 12/05/10. She was not burned. The incident report also indicated the resident was ""blind"". On 02/23/11 at 9:30 a.m., this resident was observed and interviewed in her room. Upon inquiry, the resident stated she was not blind, but she could not see ""very well at all"". Review of the resident's medical record, on 02/23/11, revealed she had spilled coffee on herself at noon on 12/05/10 and again on 01/30/11 at breakfast. The resident's care plan, when reviewed on 02/23/11, was found to contain the following undated handwritten intervention: ""Travel mug /c (symbol for 'with') lid @ (symbol for 'at') meals for coffee."" On 02/24/11 at 12:45 p.m., the resident was observed in her room, just prior to the receipt of her noon meal. She was drinking coffee from a regular cup, not a travel cup with a lid. At 1:00 p.m., the director of nursing (DON - Employee #118) was asked to join the surveyor at the resident's room. The resident was asked if she had a cup of coffee before her meal, and she responded she had. Employee #118 was able to observe the regular cup on the resident's overbed table at this time. On 02/25/11, Employee #23 (a licensed practical nurse - LPN) was asked to provide this resident's ""Resident Care Flow Record"" which nursing assistants are supposed to follow in providing resident care. There was a handwritten (but not dated) note on the flow sheet, with an asterisk beside of it, which said, ""Travel mug /c lid @ meals for coffee."" The resident was not provided a travel cup with a lid for her coffee, on 02/24/11, as directed by her care plan. -- b) Accident hazards: 1. During the initial tour at 3:15 p.m. on 02/22/11, Resident #41 was observed with a very red face and was coughing. Two (2) staff members (Employees #30 and #7) were in the room but did not appear to notice anything happening with the resident. Another resident's family member had to summon the employees to help the resident. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, on 02/23/11, revealed he was assessed with [REDACTED]. The resident's care plan, dated 02/14/11, contained the following goal: ""Resident will have no unidentified s/s (signs and symptoms) of aspiration through the next review 05/14/11."" One (1) of the interventions for this goal was: ""Monitor for increased incidence of choking, coughing during meals or PO (by mouth) intake, red face, watery eyes, difficulty breathing and notify MD (physician)."" Interview with the rehabilitation manager (Employee #38), on 02/24/11 at 1:15 p.m., revealed the resident had placed more than one (1) cheese puff in his mouth. Had adequate supervision been in place while he was eating, staff could have directed him to finish one (1) cheese puff before putting another in his mouth. On 02/22/11 at 3:15 p.m., this resident was not supervised while eating, to prevent choking. - 2. Review of accident and incident reports, on 02/23/11, revealed Resident #16 spilled coffee on herself on 12/05/10. She was not burned. The incident report also indicated the resident was ""blind"". On 02/23/11 at 9:30 a.m., this resident was observed and interviewed in her room. Upon inquiry, the resident stated she was not blind, but she could not see ""very well at all"". Review of the resident's medical record, on 02/23/11, revealed she had spilled coffee on herself at noon on 12/05/10 and again on 01/30/11 at breakfast. The resident's care plan, when reviewed on 02/23/11, was found to contain the following undated handwritten intervention: ""Travel mug /c lid @ meals for coffee."" On 02/24/11 at 12:45 p.m., the resident was observed in her room, just prior to the receipt of her noon meal. She was drinking coffee from a regular cup, not a travel cup with a lid. At 1:00 p.m., the DON was asked to join the surveyor at the resident's room. The resident was asked if she had a cup of coffee before her meal, and she responded she had. Employee #118 was able to observe the regular cup on the resident's overbed table at this time. On 02/25/11, Employee #23 was asked to provide this resident's ""Resident Care Flow Record"" which nursing assistants are supposed to follow in providing resident care. There was a handwritten (but not dated) note on the flow sheet, with an asterisk beside of it, which said, ""Travel mug /c lid @ meals for coffee."" The resident was not provided an assistive device to prevent accidents (a travel cup with a lid for her coffee) on 02/24/11, in accordance with her care plan. -- c) Food preparation and appearance: 1. 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 DON at the time of the observation. The NHA confirmed the meals for residents on pureed diets were not appetizing or attractive. - 2. 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. -- 3. 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). State law requires cold foods, at the time of service, 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. -- d) Infection control: 1. Review of Resident #38's medical record revealed a discharge summary from a local hospital, dated 02/17/11, with a discharge [DIAGNOSES REDACTED]. Review of Resident #38's facility admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 02/18/11 at 3:00 a.m., revealed the resident remained on antibiotic therapy due to a positive [MEDICAL CONDITION] culture. A nurse's note, dated 02/18/11 at 12:00 p.m., revealed the resident changed rooms due to positive [MEDICAL CONDITION] with five (5) days of antibiotic therapy remaining. An interview with Employee #64, on 03/01/11, revealed Resident #38 was placed in isolation ""a little before 12:00 p.m. on 02/18/11."" Employee #64 also stated the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the facility policy regarding ""Isolation - Categories of Transmission - Based Precautions"" revealed contact precautions should be implemented ""for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ... Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g. the individual is incontinent on the floor, or wanders and touches others)."" Review of Resident #38's medical record revealed the resident was incontinent of bowel and bladder, and observation revealed she was able to ambulate in her wheelchair. For example, on 02/22/11 at 3:20 p.m. and again on 03/01/11, she was observed ambulating in her wheelchair within her room, and on 03/02/11 at 1:45 p.m., she was observed sitting in the doorway of her room in her wheelchair. - 2. On 02/23/11 at 1:50 p.m., a nursing assistant (#95) was observed passing ice on the East Hall. She was holding the pitchers, taken from residents' rooms, over the ice in the ice chest as she filled each pitcher. This practice created a potential for cross contamination. At the time of the observation, a registered nurse (Employee #105) was shown the practice and confirmed Employee #95 should not hold the pitchers over the ice while filling them. -- e) Accurate and complete clinical records: 1. Resident #48 Review of Resident #48's medical record revealed that, on 12/28/10, two (2) physician's orders had been discontinued: float heels while in bed and elevate legs while in bed. At this time, the resident had a pressure ulcer to her right heel. On 03/01/11 at 3:50 p.m., an interview with the director of nursing (DON - Employee #118) revealed these orders must have been discontinued accidently while the facility was trying to reduce the number of unneeded physician's orders. ""It must have been an oversight."" - 2. Resident #67 Review of Resident #67's medical record revealed dietary progress notes written by the dietician (dated 12/03/11 and 01/25/11) that were not legible. On 03/02/11 at 2:20 p.m., an interview with the administrator (Employee #117) revealed he was only able to read ""bits and pieces"" of the documentation. - 3. Resident #41 During the initial tour at 3:15 p.m. on 02/22/11, this resident was observed with a very red face and was coughing. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, during the afternoon of 02/23/11, revealed no documentation regarding this resident had choked on cheese puffs on 02/22/11. On 02/28/11 at 3:10 p.m., the DON stated a registered nurse (Employee #68) went to the activity room and checked the resident but did not document anything. - 4. Resident #30 Review of this resident's medical record, on 02/23/11, revealed the resident was sent to the emergency room for evaluation on 01/28/11. The resident's medical record contained no evidence the resident was provided any of the required notices upon transfer, including but not limited to readmission rights. The facility later located this information. - 5. Resident #8 Review of this resident's current medical record revealed it contained a medical power of attorney document for another resident.",2015-01-01
10647,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,226,E,0,1,W65Z11,"Based on a review of the facility's abuse policy, personnel files, and staff interview, the facility failed to assure their written policies and procedures were designed to prohibit mistreatment abuse, neglect, of residents and misappropriation of resident property. The policies were not clear and did not contain adequate information in the areas of pre-employment screening, training, prevention and identification. It was not clear when this policy was developed or last reviewed. By not developing specific policies to resident prevent abuse / neglect, and misappropriation of property, there was no evidence to reflect the facility was doing everything within their control to prevent such occurrences. This practice has the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) Abuse Policy and Procedures Review of the facility's ""Abuse Policy and Procedure"", on 08/25/09, found this policy to be very brief in length. Further review revealed this policy did not cover in detail, as required, the areas of pre-employment screening, training, prevention and identification, to assure the facility was detecting and preventing resident abuse, neglect, and misappropriation of property occurrences to the extent possible. 1. Pre-employment screening In the area of ""screening"", the facility's policy did not include how they would screen backgrounds for those who indicated that they had worked, lived, or attended school in another state. It was unclear how the facility would assure these staff members did not have criminal backgrounds in the states of prior employment / residence, etc. that would make them unfit to work in a nursing facility. The area of screening did not specify what thresholds would have to be exceeded (e.g., barrier crimes) that would result in not hiring an applicant to work in the nursing facility . Review of the sampled employees' personnel files, on 08/27/09, revealed the facility had identified two (2) individuals (Employees #22 and #69) who had previous work history in other states. Employee #69 was hired on 06/01/09. He was suspended from his position 08/20/09 when he exhibited behaviors that triggered the facility to do a further check into his criminal background. On 08/25/09, the facility discovered he did have a criminal background in one (1) of the states listed on his work history. There was no evidence the facility attempted to check employees' backgrounds for past criminal convictions when they indicated having lived, worked, or attended school outside of West Virginia. The facility did perform a fingerprint background checks on applicants, but this only served to inquire about criminal convictions in West Virginia. b) Training In the area of ""training"", there facility's policy was unclear. The policy said each new employee would be informed of the reporting obligations and that training would include examples of reportable incidents to assist staff in detection of such incidents. The policy said this training should be offered no less than annually. However, the training did not address acceptable ways for staff to deal with aggressive behaviors and/or catastrophic reactions; instruction regarding what constituted resident abuse, neglect, and misappropriation of property; how to immediately report suspicions or allegations of abuse (including injuries of unknown origin), neglect, or misappropriation of property; how to report knowledge related to abuse allegations without fear of reprisal; and how to recognize signs of burnout, frustration and stress that may lead to abuse. c) Prevention In the area of ""prevention"", the facility's policy stated staff, families, and residents shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident's property without fear of reprisal. This was the entire policy statement for ""prevention"". The policy did not specify the process by which they would prevent such occurrences, such as supervising / monitoring, deployment of staff to assure the numbers are sufficient, listening for harsh language, observing of inappropriate behaviors, observing for roughness, assessing and care planning interventions for resident behaviors that might lead to conflict, etc. d) Identification In the area of ""identification"", the facility's policy simply stated, ""All staff will be inserviced annually regarding how to identify and report suspected abuse."" This was the entire procedure for identification. The policy did not include identifying events such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse and assist with directing the investigation. e) During an interview with the administrator on the afternoon of 08/26/09, she verified this was the policy they utilized, but she did not have evidence of when this policy was initiated or whether it had ever been reviewed or revised. At that time, this nurse surveyor informed her the policy failed to adequately address key requirements. .",2015-01-01
10648,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,221,D,0,1,W65Z11,"Based on observation, record review and staff interview, the facility failed to assure side rails were used on residents only after being properly assessed for the necessity of these devices. A staff member was observed putting up full length side rails when Resident #4 was sleeping. It was indicated in the medical record that this resident did not require the use of bed rails on her bed. Applying these devices for a resident when there is no indication for their use was observed for one (1) of fifteen (15) sampled residents. Resident identifier: #4. Facility census: 59. Finding include: a) Resident #4 During an observation of Resident #4 on 08/26/09 at 4:00 p.m., Employee #34 put up bilateral full length side rails on the bed of this resident. Review of the medical record revealed a physician's order for a lateral support when the resident was up in the chair because she had a tendency to lean to the side. However, there was no physician's order to utilize side rails for this resident. Further review of the medical record found a bed safety assessment completed on 12/14/08. This assessment indicated no rails were present on this bed and there was no indication for side rail use for this resident. The director of nursing (DON), when questioned about the use of side rails for this resident on 08/26/09 at 5:00 p.m., confirmed there was no indication for this resident to utilize side rails. .",2015-01-01
10649,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,225,E,0,1,W65Z11,"Based on a review of sampled employees' personnel records, policy review, and staff interview, the facility failed to conduct thorough background checks on applicants who had identified previous residences, work histories, and/or educational experiences in other States, in order to uncover information about any past criminal convictions that would indicate unfitness for employment in a nursing facility. This was true for two (2) of five (5) sampled employees, and this practice has the potential to affect more than an isolated number of residents. Employee identifiers: #22 and #69. Facility census: 59. Findings include: a) Employees #22 and #69 On 08/27/09, a review of sampled employees' personnel files found two (2) individuals who had identified on their employment applications having had residences, work experiences, and/or educational experiences in other states. Employee #22 listed on her application for employment having worked in Jackson, Wyoming and Knoxville, Tennessee. There was no evidence the facility checked for criminal backgrounds in these states. Employee #69 was a nursing assistant who was hired on 06/01/09. He indicated on his application for employment having worked in South Boston, Virginia and Washington, DC within the past two (2) years. There was no evidence the facility attempted to check this employee's background for past criminal convictions that would make him unfit to work in the nursing home in states of his prior employment. After an incident involving another employee and Employee #69, on 08/20/09, this employee was suspended. A national background check was then conducted on 08/25/09, and the facility did uncover a criminal background in a state where he was previously employed. This employee was then terminated from this facility. The facility currently conducts fingerprinting of all employees. The fingerprints are sent to the West Virginia State Police for investigation of crimes committed in the State of West Virginia. Review of the facility's policy titled ""Abuse Policy and Procedure"" found no written procedure to ensure pre-employment screening included checking for evidence of criminal convictions in states when information provided on an individual's employment application indicates work experiences, residence, and/or educational experiences in other states. During an interview on 08/27/09 at 10:00 a.m., Employee #10 confirmed the facility did not conduct criminal backgrounds in the other states when an individual's employment application reveals the applicant has lived or worked outside of West Virginia. .",2015-01-01
10650,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,248,E,0,1,W65Z11,"Based on group interview, family interview, activity calendar, activity staff schedule, and staff interview, the facility failed to provide an activity program designed to meet the assessed needs of the residents. It was identified that this facility had a large number of residents who wandered, with eleven (11) of fifty-nine (59) residents who wandered and would benefit from activity programming late in the evening. There were no planned activities scheduled to decrease this behavior for these residents, which affected the other residents in the facility. Resident identifiers: #10, #14, #18, #25, #28, #29, #31, #33, #40, #57, and #58. This practice has the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) Activity Program A review of the monthly activity calendars for August and September 2009 revealed, in each of these months, there were only five (5) evening activities (after dinner) scheduled for the entire month. Each of those five (5) activities that was scheduled in the evening was a church service. There were no other evening activities scheduled. During a confidential interview on 08/26/09, a family member related having frequently observed, when visiting this facility in the evening, a lot of residents who wandered into other residents' rooms and bothered things. The facility had no structured activities going on for these cognitively impaired residents who were active in the evening, and the staff trying to provide care to the other residents often had to interrupt resident care to try to deal with the behaviors of these wandering residents. During a confidential resident group interview held on 08/26/09 at 10:00 a.m., six (6) of six (6) alert and oriented residents interviewed agreed the behaviors of that wandering residents were a problem. They related the facility had been made aware of this and had tried using stop signs on the doors, but this did not work. The group agreed this occurred mostly in the evening and late at night. They all agreed it was not a problem in the day time. A review of the activity staff schedule revealed three (3) full time activity staff members at this sixty (60) bed facility. According to the schedule, their work hours were 10:00 a.m. - 6:30 p.m., 8:00 a.m. - 4:30 p.m., and 7:00 a.m. - 3:30 p.m. There were no activity staff members present in the facility after 6:30 p.m. An interview with the activity staff (Employee #43), on 08/26/09 at 2:30 p.m., revealed eleven (11) residents who wandered around the facility. It was verified there were no activity staff schedule for evenings, but they do have available puzzles, magazines, etc. in the TV room. She verified the only evening activities scheduled were church services five (5) times during the month. .",2015-01-01
10651,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,356,C,0,1,W65Z11,"Based on observation and staff interview, the facility failed to assure the nursing staffing data were current and posted on a daily basis at the beginning of each shift. The posting was not complete for the evening shift at 5:30 p.m. on 08/24/09. This posting was to allow the public visitors to know how many staff members are caring for the residents at any given time. Not posting this information has the potential to affect anyone who would like to review the facility's current staffing. Facility census: 60. Findings include: a) Review of the required posting for the number of caregivers in the facility and the hours worked, at 5:30 p.m. on 08/24/09, revealed the evening shift (3:00 p.m. to 11:00 p.m.) nursing staffing data had not been posted. The nurse (Employee #10) was made aware this posting was blank for the evening shift, and she confirmed it should have been completed at the beginning of the shift. She completed the information at 5:32 p.m. .",2015-01-01
10652,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,428,D,0,1,W65Z11,"Based on record review and staff interview, the facility failed to assure a physician reviewed and acted upon the consultant pharmacist's recommendations. The pharmacist identified a resident was receiving two (2) antidepressants and recommended the physician consider discontinuing one (1) of them. There was no evidence to reflect this recommendation was acted upon. This was true for one (1) of fifteen (15) sampled residents. Resident identifier: #5. Facility census: 59. Findings include: a) Resident #5 Medical record review, on 08/25/09 at 3:00 p.m., revealed a consultant pharmacist's report dated 06/13/09, which identified Resident #5 was on two (2) antidepressants. The pharmacist recommended the physician consider the discontinuation of one (1) of these antidepressants. The physician responded to this recommendation with the following, ""Antidepressants managed by her longtime psychiatrist."" Review of the medical record found no evidence to reflect the psychiatrist was asked to review the pharmacist's recommendation. A request was made, on 08/25/09, for any outstanding psychiatric consults that may not yet have been filed on Resident #5's active record. On 08/25/09 at 2:31 p.m., the psych consult reports, which had been were faxed that day to the facility, were reviewed. The most recent psych consult for this resident occurred on 05/29/09, prior to receipt of the pharmacist's recommendation. On 08/25/09, the director of nursing (DON - Employee #69) was informed of this situation and had no additional information to provide. The facility failed to act on a pharmacy recommendation. .",2015-01-01
10653,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,315,E,0,1,W65Z12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to provide treatment and services to restore as much normal bladder function as possible for two (2) of nine (9) sampled residents. Each of these residents had a decline in bladder continence but were not assessed for the causal factors for the incontinence. In addition, no interventions were established to help restore or maintain bladder function for these individuals. Resident identifiers: #2 and #38. Facility census: 59. Findings include: a) Resident #2 This resident was admitted to the facility on [DATE]. Her initial minimum data set (MDS), with an assessment reference date (ARD) of 04/14/09, indicated the resident was coded ""2"" - occasionally incontinent of urine. Review of the resident's quarterly MDS, with an ARD of 07/17/09, revealed the resident was coded ""4"" - incontinent of bladder. The next quarterly MDS also noted the resident was ""4"" - incontinent. The facility had not assessed the change in the resident's continence, had not evaluated the resident for causal factors, and had not implemented any interventions in effort to restore normal bladder functioning. On 12/03/09, this resident's medical record was reviewed. This review revealed that, on 10/07/09, the facility implemented a three (3) day continence diary, which was completed on 10/09/09. There was no evidence that anything else was done regarding the resident's incontinence. There was no evidence the facility had evaluated the results of the voiding diary, evaluated the resident for causal factors, or implemented any interventions in effort to restore normal bladder functioning. On 12/03/09 at 3:50 p.m., the assistant director of nursing (ADON) stated the resident could usually tell staff when she needed to void. At 4:30 p.m., the ADON confirmed the facility had not completed a thorough evaluation of the resident's incontinence and had not implemented any interventions in effort to restore normal bladder functioning for this resident. It should be noted that this resident was cited for the same situation during the previous survey, which ended on 08/27/09. b) Resident #38 This resident's medical record was reviewed on 12/03/09. A quarterly bowel and bladder assessment, dated 11/12/09, was reviewed. It indicated, ""No changes in bowel and bladder status since last assessment... notifies staff when she needs to be toileted, has episodes of incontinence."" Review of the activities of daily living (ADL) flow records for November 2009 revealed documentation that the resident had been incontinent on all three (3) shifts everyday. This information was incongruent with the bowel and bladder assessment. An interview with the nurse, who was responsible for bowel and bladder assessments, at 1:45 p.m. on 12/03/09, revealed the resident had not been assessed for the causal factors for the incontinence and no interventions had been established to help restore or maintain bladder function for the resident. The nurse stated she had ""missed"" this resident and the resident should have been placed on a three (3) day diary to evaluate the incontinence. c) The facility's bowel and bladder retraining program was reviewed. According to this policy, the facility should have determined the type of incontinence and implemented a voiding diary for each resident. Once these processes were completed, the policy indicated the facility should have evaluated each resident for a behavioral bladder training program and implemented the program. None of this was completed for either resident. .",2015-01-01
10654,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,492,D,0,1,W65Z12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide information regarding hospice to one (1) resident, of nine (9) sampled residents, who had a physician's orders [REDACTED]. This is required by West Virginia Code 16-5C-20. Resident identifier: #17. Facility census: 59. Findings include: a) Resident #17 Medical record review, on 12/03/09, revealed this resident had a physician's orders [REDACTED]. Further review revealed no evidence the resident and family had been provided information regarding hospice. Interview with the social worker, on 12/03/09 at 1:15 p.m., revealed this information had not been provided.",2015-01-01
10655,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,364,F,0,1,W65Z11,"Based on observation and resident interview, the facility failed to assure foods were attractive and appetizing as served. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 59. Findings include: a) During the confidential group interview with the residents at 10:15 a.m. on 08/26/09, the residents in attendance reported the meals were not attractive. One (1) resident even stated, ""It almost turns your stomach when you take the lid off."" b) Observation of the noon meal, on 08/26/09, revealed a lack of variety in color. The menu was pork chops, potatoes, squash, roll, Snickerdoodles, and milk. All these items were observed to be white to pale yellow. Additionally, there were no garnishes or other means to improve the appearance of the meal. At 1:00 p.m. on 08/26/09, this was discussed with the dietary manager, who confirmed that menu changes and garnishes would enhance the appearance of the meals. c) During observation of the noon meal on 08/27/09, pureed meat and carrots were thin, ran into each other, and spread over the plates, resulting in an unattractive, unappetizing meal for residents who required pureed diets. .",2015-01-01
10656,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,371,F,0,1,W65Z11,"Based on observation, food temperature measurement, and staff interview, the facility failed to assure that foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 59. Findings include: a) On 08/27/09 at 11:15 a.m., a dietary employee was observed without a beard protector. Effective hair and beard coverings are required to protect food and food service surfaces from the potential contamination by hairs falling into foods and onto food surfaces. b) At 11:15 a.m. on 08/27/09, bowls, cups, and plate covers were observed to be stacked inside of each other or inverted on trays prior to air drying. These items were observed with trapped moisture, creating a medium for bacterial growth. c) During observations in the kitchen, at noon on 08/27/09, various dietary personnel were observed washing hands, then re-contaminating them by lifting a barrel lid, turning off faucets with bare hands, and/or turning off faucets with towels, then drying hands again with the soiled towels. d) During the initial tour, on 08/24/09, Gatorade was observed in the refrigerator. It was dated 08/06/09. Undated tomato juice was also observed. e) On 08/24/09, a portion of ham was being held for one (1) resident for the evening meal. It was not being held in any type of food temperature holding device. When measured, the ham was 122 degrees Fahrenheit. f) These sanitation infractions were discussed and confirmed with the dietary manager at 1:00 p.m. on 08/26/09 and at 11:15 a.m. on 08/27/09. .",2015-01-01
10657,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,363,E,0,1,W65Z11,"Based on review of menus, medical record review, observation, and staff interview, the facility failed to assure that menus were prepared in advance and/or that menus were followed for ten (10) of fourteen (14) residents reviewed. Resident Identifiers: #1, #5, #8, #18, #21, #22, #47, #48, #51, and #59. Facility census: 59 Findings include: a) Resident #1 Medical record review, on 08/26/09, revealed this resident was ordered a 1200 calorie diet. According to the menu, at noon on 08/27/09 this resident was to be provided 1/3 cup (c) of low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. b) Resident #5 Medical record review, on 08/26/09, revealed this resident was ordered a 4 gram sodium low cholesterol / low fat diet. According to the menu, at noon on 08/27/09 this resident was to be provided 3 oz low sodium pepper steak/gravy, 1/2 c low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 3 oz regular pepper steak / gravy, 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. c) Resident #8 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / low fat diet. According to the menu, at noon on 08/27/09 this resident was to be provided 1/2 c low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. d) Residents #21, #51, and #59 Medical record review, on 08/26/09, revealed each of these resident was ordered a ""diabetic"" diet. Review of the menu and tray cards revealed there was no plan for this diet. e) Residents #18 and #29 Medical record review, on 08/26/09, revealed each of these residents was ordered an 1800 calorie diet. According to the menu, at noon on 08/27/09 these residents were to be provided 1/3 c of low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the residents were provided 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. f) Resident #22 Medical record review, on 08/26/09, revealed this resident was ordered a 1500 ADA NAS finger foods diet. According to the menu, at noon on 08/27/09 this resident was to be provided a 1500 calorie diet with pepper steak bites and rice fritters. Observation of the noon meal, on 08/27/09, revealed these finger foods were not available to serve. Additionally, the resident was not provided low fat items as required by the 1500 calorie diet plan. g) Resident #47 Medical record review, on 08/26/09, revealed this resident was ordered a vegetarian low fat/low cholesterol NCS diet. Review of the menu and resident's tray card revealed no plan for this diet. h) On 08/27/09 at 1:30 p.m., an interview with the cook who served the meal was conducted. At that time, it was confirmed that the low fat foods, low sodium foods, and finger foods had not been prepared and available to serve at the noon meal. .",2015-01-01
10658,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,367,E,0,1,W65Z11,"Based on medical record review, observation, and staff interview, the facility failed to assure that each resident received foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. This practice affected seven (7) of fourteen (14) residents reviewed. Resident identifiers: #12, #21, #30, #35, #47, #51, and #59. Facility census: 59. Findings include: a) Resident #12 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / no added salt diet. Review of the tray card revealed only a ""ground"" diet. b) Residents #21, #51, and #59 Medical record review, on 08/26/09, revealed each of these residents was ordered a ""diabetic"" diet. Review of the menu and tray card revealed there was no plan for this diet. c) Resident #30 Medical record review, on 08/26/09, revealed this resident was ordered an 1800 ADA/cardiac diet. Review of the tray card revealed an 1800 ADA NAS diet. Additionally, the menu contained no plan for a ""cardiac"" diet. d) Resident #35 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / low fat diet. Review of the tray card revealed a NAS regular diet. e) Resident # 47 Medical record review, on 08/26/09, revealed this resident was ordered a vegetarian low fat / low cholesterol NCS diet. Review of the menu and resident's tray card revealed no plan for this diet. .",2015-01-01
10659,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,325,D,0,1,W65Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of menus, observation of tray cards, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of fifteen (15) sampled residents. In addition, the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition and preferences. This resident was ordered a vegetarian diet, for which there was no assessment (including nutritionally significant laboratory values) or plan to assure the provision of adequate protein and nutrients for this resident. Resident identifier: #47. Facility census: 59. Findings include: a) Resident #47 Medical record review, on 08/26/09, revealed this resident had a physician's orders [REDACTED]. Review of the menu and the resident's tray card revealed no plan to provide a vegetarian diet which suppled adequate protein and other nutrients. Observation of the noon meal, on 08/27/09, revealed the resident was provided rice, potatoes, green beans, tomato juice, and no milk. Inquiry of dietary staff revealed they provided the resident what was on the menu, excluding meat, plus another vegetable. Medical record review revealed there was no evaluation of the resident's protein and nutrient needs and no plan to assure adequate protein and nutrient intake. For example, there were no laboratory values for [MEDICATION NAME] or pre-[MEDICATION NAME] to help identify impaired nutrition. .",2015-01-01
10660,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,318,D,0,1,W65Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure Resident #4, who had severe contractures to both of her hands, received care and services to prevent further contractures. The facility also failed to implement a physician's orders [REDACTED]. This practice was observed for one (1) of fifteen (15) residents. Resident identifier: #4. Facility census: 59. Findings include: a) Resident #4 Observation, on initial tour on 08/24/09 at 5:00 p.m., found this resident sitting in the hallway in a geri-chair with lateral supports on her chair for positioning. She had severe contractures to both hands and did not have any type of devices in her hands for the contractures. This was observed again in the mornings and afternoons of 08/25/09 and 08/26/09. Review of the medical record for Resident #4 revealed occupational therapy had treated this resident in March 2009 for splinting / palm protectors of her hands. It was then recorded that education was given to the nursing assistants, and the resident was discharged to the services of a restorative nursing program (RNP) for splinting on 03/04/09. Review of the resident's care plan found an intervention related to the hand contractures had been discontinued on 06/17/09; this discontinued intervention stated, ""RNP to wash hands / place cones per order to avoid pressure."" After this RNP intervention was discontinued, there was no further evidence this resident's severe contractures were addressed on the comprehensive care plan. This resident was observed multiple times throughout the survey, at various times of the day, with no cones, palm protectors, braces, or any other type of interventions for her hand contractures. She was observed each day from 08/24/09 to 08/26/09, throughout the day and on both day and evening shifts. There was nothing observed in her hands for treating the contractures. It could not be verified through reviewing the medical record or the nursing assistant assignments exactly what the current treatment of [REDACTED]. The July 2009 nursing assistant flow sheet stated, ""Place clean wash cloth in hands each day."" However, this was intervention not observed in have been implemented either. Employee #34 was assigned this resident at 4:00 p.m. on 08/26/09. She stated she was not aware whether the resident was supposed to have palm protectors, and she stated this resident was not on her usual assignment. It was observed at that time that there was a sign on the closet door that said, ""Bilateral palm protectors are to be worn 3 hours in the morning then removed and replaced again in the evening from 3 hours. Please remove palm protectors at night when sleeping."" There was no evidence this was being done, and this caregiver was not aware of it. Employee #34 then raised the sheets for the surveyor to look at the resident's feet. She was sleeping, and her heels were pressed against the mattress. A review of the physician's orders [REDACTED]."" There was no evidence this was being done. The director of nursing (DON) was made aware, on 08/27/09 at 3:00 p.m., of the observations with respect to Resident #4. She confirmed the directions in the medical record for the treatment of [REDACTED]. She was also notified that the heels were not elevated as ordered. .",2015-01-01
10661,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-09-09,246,D,1,0,6V5K11,"**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 evaluate and individualize the call bell for one (1) of eight (8) sampled residents. The resident, whose only movement was in the left hand and fingers, could not reach for or operate the push button style call bell. Resident identifier: #48. Facility census: 77. Findings include: a) Resident #48 On 09/08/11 at 12:55 p.m., this resident was observed lying in bed with the push style call bell clipped to the sheet below the resident's left side. When asked if the resident could use the call bell, the resident responded, ""Yes."" When asked to demonstrate the use of the call bell, the resident moved the contracted fingers and thumb of his left hand as if to press the call bell, but the call bell was not in his hand. He did not recognize the call bell was not in his hand. When it was explained that the call bell was not in his hand, the resident stated he once had a call bell that he could use by moving his head, but he did not know what happened to it. When asked what he did if he needed help, he stated, ""I yell."" A review of the medical record revealed this [AGE] year old male had [DIAGNOSES REDACTED]. The director of nursing (DON - Employee #38) and the assistant directors of nursing (ADONs - Employees #40 and #41) were informed of Resident #48's inability to use his call bell at 2:15 p.m. on 09/08/11. Employee #41 stated she was not aware the resident could not use the call bell and that he yelled if he needed help. At 2:30 p.m. on 09/08/11, observations were made in the resident's room with Employees #40 and #41. Employee #41 placed the call bell in the resident's hand and asked the resident to activate the call bell. The resident was not able to independently hold and activate the call bell after numerous attempts. At that time, the resident was asked what he did to get help and stated, ""I yell."" Employees #40 and #41 discussed the possibility of using a pressure activated call bell. A pressure-activated call bell was obtained, and the resident was instructed in its used. Observation revealed numerous unsuccessful attempts were made to determine a placement for this call bell so the resident could find and activate it independently. . Later that afternoon, Employee #41 reported she was able to position the pressure activated call bell so that the resident could use the device. On 09/09/11 at 8:20 a.m., the resident was observed lying in his bed with the pressure activated call bell clipped on his gown in the middle of his chest. His hands were positioned in his lap. The resident was asked to activate the call bell and was not able to locate the device. When the location of the call bell was described to the resident, he attempted to move his hands to his chest. The resident was unable to move his hands out of his lap to his chest.",2015-01-01
10662,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-09-09,279,D,1,0,6V5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop and/or revise the comprehensive care plans for two (2) of eight (8) sampled residents. Resident #28 had a specific indicator regarding when she needed assistance in toileting, which was not incorporated into her care plan. Resident #48 was unable to activate the type of call light he was provided. Additionally, this resident required specific placement of a call light to afford the resident the ability to activate the device. Neither of these specific needs were a part of this resident's care plan. Resident identifiers: #28 and #48. Facility census: 77. Findings include: a) Resident #28 Review of this resident's medical record, on 09/08/11, revealed this confused resident was usually continent of urine. According to her care plan dated 08/04/11, the resident was ""...occasionally incontinent of urine r/t (related to) dementia, impaired mobility, and impaired cognition."" An interview was conducted with one (1) of the facility's assistant directors of nursing (ADONs - Employee #40) at 1:00 p.m. on 09/08/11. In discussing this resident's incontinence, Employee #40 revealed the resident ""gets fidgety when she has to go to the bathroom."" Further review of the resident's care plan noted the goal for the resident's incontinence was: ""Resident will demonstrate improved urinary elimination control as evidenced by experiencing less than daily episodes of urinary incontinence."" This goal was initiated on 08/04/11. The interventions for the goal were: ""Complete a voiding diary and evaluate for patterns of incontinence at appropriate intervals. Encourage resident to consume fluids during meals. Complete an incontinence assessment at intervals according to policy and procedure. Observe for signs and symptoms of infection and report to physician if noted. Observe skin daily with ADL (activities of daily living) care and notify nurse of abnormality / deficit in skin integrity. LN (licensed nurse) will also continue weekly skin audit and will notify physician of any deficits in skin integrity noted. Provide privacy and comfort. Provide skin care after each incontinent episode."" While all the above interventions were good directives for nursing staff, the interventions were not resident-specific. They were very general in nature and failed to address a very important fact the facility already knew about the resident. None of the interventions addressed the fact the resident ""gets fidgety when she has to go to the bathroom."" There was no intervention to assist the resident to the bathroom at these times. -- b) Resident #48 This resident medical record, when reviewed on 09/08/11, disclosed this [AGE] year old male had [DIAGNOSES REDACTED]. Review of the care plan revealed the following intervention: ""Place call light within reach at all times."" This intervention had an initiation and creation date of 04/26/11 by a registered professional nurse (RN - Employee #34). On 09/08/11 at 12:55 p.m., this resident was observed lying in bed with the push style call bell clipped to the sheet below the resident's left side. When asked if the resident could use the call bell, the resident responded, ""Yes."" When asked to demonstrate the use of the call bell, the resident moved the contracted fingers and thumb of his left hand as if to press the call bell, but the call bell was not in his hand. He did not recognize the call bell was not in his hand. The director of nursing (DON - Employee #38) and the ADONs (Employees #40 and #41) were informed of Resident #48's inability to use the call bell at 2:15 p.m. on 09/08/11. Employee #41 stated she was not aware the resident could not use the call bell. At this time, a discussion was held regarding a failure of the care plan to accurately reflect this resident's individual needs regarding the use of a call bell. At 2:30 p.m. on 09/08/11, observations were made in the resident's room with Employees #40 and #41. Employee #41 placed the call bell in the resident's hand and asked the resident to activate the call bell. The resident was not able to independently hold and activate the call bell after numerous attempts. The facility had not developed a care plan which accurately reflected the individual needs of this resident regarding the use of a call bell. .",2015-01-01
10663,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-09-09,282,D,1,0,6V5K11,"**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 plan of care for one (1) of eight (8) sampled residents. The facility failed to ensure a splint was applied to the resident's left hand in accordance with the care plan. Resident identifier: #48. Facility census: 77. Findings include: a) Resident #48 A review of the medical record, 09/08/11, revealed this [AGE] year old male had [DIAGNOSES REDACTED]. On observation on 09/08/11 at 12:55 p.m., revealed all fingers and thumb on the left hand were contracted. Review of the most recent care plan, on the morning of 09/08/11, revealed the resident was to have an adjustable Pilo-splint applied to the left hand at 8:00 a.m. and removed at 2:00 p.m. The care plan indicated the date of initiation was 04/26/11, with a creation date of 05/03/11, by a registered professional nurse (RN - Employee #34). This resident was observed in his room on 09/08/11 at 12:55 p.m., and again on 09/09/11 at 8:20 a.m., with no splint on his left hand. On 09/09/11 at 10:15 a.m., the director of nursing (DON - Employee #38) and the assistant directors of nursing (ADONs - Employees #40 and #41) were informed Resident #48 was observed without his splint on 09/08/11 and 09/09/11.",2015-01-01
10664,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-09-09,315,D,1,0,6V5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, policy review, and staff interview, the facility failed to assure one (1) incontinent resident, of eight (8) sampled residents, was provided services to restore as much normal bladder function as possible. This resident was not assessed or provided services to achieve or maintain as much normal urinary function as possible when her catheter was removed and/or as she continued to experience frequent episodes of incontinence. Resident identifier: #37. Facility census: 77. Findings include: a) Resident #37 Medical record review, on 09/08/11, revealed this resident was admitted to the facility from the hospital on [DATE]. She had a urinary catheter upon admission. On 04/04/11, the catheter was removed. There was no evidence the facility assessed the resident for a plan to restore as much normal bladder function as possible when the catheter was removed. There was also no assessment regarding the type of urinary incontinence, or the causes of the incontinence, to allow for the provision of an individualized program or interventions which addressed the incontinence. An interview was conducted with the resident at 12:15 p.m. on 09/08/11. At that time, the resident stated she could feel the urge to void. Additionally, the resident said she would like to participate in bladder retraining if the facility determined it was appropriate for her. She expressed a desire to be assisted in becoming continent if at all possible. At 1:00 p.m. on 09/08/11, an interview was conducted with one (1) of the facility's assistant directors of nursing (ADONs - Employee #40). The ADON stated the facility should have initiated a three (3) day continence management diary when the catheter was removed, to assess the resident's continence / incontinence. Based on the results of the diary, the resident should have been offered a restorative urinary continence management program, or other toileting program as appropriate. Upon request, Employee #40 reviewed Resident #37's medical records and reported the resident had not been assessed for the need for these services when the catheter was removed on 04/04/11. Employee #40 produced a three (3) day continence management diary, which was initiated on 06/23/11; however, there was no evidence the results of that diary had been evaluated and/or used to consider whether the resident might benefit from an individualized bladder restoration program. The facility's policies for catheter removal and continence management were reviewed. Each policy had a revision date of 10/01/10. These policies provided specific directives for catheter removal and continence management. Neither policy had been implemented for Resident #37 when the catheter was removed, or when the resident continued to have frequent episodes of incontinence. Later in the afternoon on 09/08/11, Employee #40 was interviewed again. Employee #40 stated she had visited Resident #37. The visit resulted in the resident stating she wanted to try a bladder restoration program. A voiding diary was implemented at that time (on 09/08/11). During this interview, Employee #40 confirmed the facility's policies for catheter removal and continence management had not been implemented for Resident #37.",2015-01-01
10665,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,280,D,0,1,K6RU11,"**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 after a resident's fall to help prevent future accidents, and failed to revise a care plan after a resident's continued refusal and disuse of a wedge. These findings were evident for two (2) of twenty-seven (27) Stage II sample residents. Resident identifiers: #19 and #28. Facility census: 68. Findings include: a) Resident #19 Record review revealed Resident #19 slipped from his recliner chair and slid onto the floor on 09/13/10, with no known injury. The facility completed an accident / incident report per protocol, which contained a section for ""recommended steps to prevent recurrence"". In this section, the nurse who completed this form said, ""Recliner chair was not reclined after lunch. . . and all CNAs (certified nursing assistants) counseled on putting dicem (sic) under Resident as ordered."" The aide caring for the resident that day was also counseled on ""reclining resident's chair"". Review of Resident #19's care plan revealed no revision to address fall prevention by placing the resident's chair in a reclining position to prevent future occurrences, although the nursing assistant who was involved in this incident was counseled on reclining the resident's chair, and all nursing assistants were counseled related to putting Dycem (a non-slip material) under the resident when he is up in the chair. During an interview with the assistant director of nursing (ADON) and the director of nursing (DON) on 09/29/10 at 11:30 a.m., they reviewed the resident's comprehensive care plan, looked at some type of episodic care plan, and then agreed the care plan was not revised to include the 09/13/10 fall or the intervention to keep the recliner chair in the reclining position when not directly attended. They also looked at the Kardex in the ADL book and saw that the Kardex was not updated regarding the positioning of the recliner chair to help prevent future falls, although the Dycem was mentioned both on the Kardex and on the original care plan, as it was ordered by the physician. b) Resident #28 A review of Resident #28's medical record revealed current physician orders [REDACTED]. Observations, on 09/29/10 at 9:40 a.m., found the resident did not have any foam wedge under her legs. Employee #7 (a nurse aide) entered the room and was asked about the foam wedge. He looked around the room and finally located it on top of the wardrobe. He took it down and placed it under the resident's legs. She vocalized discomfort when he moved her legs and positioned the wedge in place. The surveyor asked her if she liked the foam wedge and if that helped her legs to feel better. She immediately replied, ""NO!"" Another observation, on 09/30/10 at 8:15 a.m., found the foam wedge was present on the bed but not under the resident's legs. Interview with Employee #20 (a licensed practical nurse - LPN) and Employee #7 (a nurse aide), at different times throughout the survey, revealed the resident refused to leave the wedge in place and did not use it. Resident #28 would remove the wedge on her own from under her legs after it was placed there. The current care plan, dated as effective from 04/15/10 to 10/14/10, stated the resident's heels were to be up on a pillow or wedge while in bed; this was an intervention associated a problem of pressure ulcers. The DON, in an interview at 11:53 a.m. on 09/30/10, agreed that the resident's care plan needed to be revised related to the resident's refusal to use the wedge pillow when in bed. .",2015-01-01
10666,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,323,D,0,1,K6RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to assure the resident environment remained as free as possible of accident hazards for two (2) of twenty-seven (27) Stage II sample residents. Resident identifiers: #76 and #19. Facility census: 68. Findings include: a) Resident #76 Review of Resident #76's medical record found current physician's orders [REDACTED]. The physician also ordered the resident's call light to be available. Observations of the noon meal, on 09/30/10 at 11:41 a.m., found the resident was lying in bed when a staff member nursing assistant (NA - Employee #54) brought him his lunch tray. The aide removed the mat from the floor beside the resident's bed, placed the bedside table beside the bed with his lunch tray on it, and raised the resident's bed. She then left the room. Observation also found the resident's call light was wrapped around the assistive device attached to the bed and was out of the resident's reach. The facility failed to assure the physician's orders [REDACTED]. b) Resident #19 Record review revealed the physician ordered Dycem (a non-slip material) to be applied at all times to Resident #19's geri chair. Review of the resident's care plan revealed the following intervention to reduce the risk for falls: ""Dicem (sic) to recliner chair."" However, the facility failed to ensure that intervention was consistently implemented by staff as evidenced by a 09/13/10 accident / incident report which stated the Dycem to the recliner chair was ""not in use"" at the time the resident slid out of his recliner chair and onto the floor with no known injury. Review of the accident / incident report dated 09/13/10 found a section for recommended steps to prevent recurrence, which included proper reclining of the resident's chair which ""was not reclined after lunch"" prior to his fall. Subsequently, the nursing assistant caring for the resident that day was ""counseled on reclining Resident's chair"", and all nursing assistants were ""counseled on putting Dicem (sic) under Resident as ordered"". There was no mention that any other nursing assistants were counseled for proper reclining of the resident's chair when not directly attended by staff. Review of the nursing assistant Kardex in the ADL (activities of daily living) book found no mention of proper reclining of the resident's chair. Review of the resident's care plan contained no mention of proper reclining of the resident's chair either before or after the fall. During an interview with the assistant director of nursing (ADON) and the director of nursing (DON) on 09/29/10 at 11:30 a.m., they reviewed the resident's comprehensive care plan, looked at some type of episodic care plan, and then agreed the care plan was not revised to include the 09/13/10 fall or the intervention to keep the recliner chair in the reclining position when not directly attended. They also looked at the Kardex in the ADL book and saw that the Kardex was not updated regarding the positioning of the recliner chair to help prevent future falls, although the Dycem was mentioned both on the Kardex and on the original care plan, as it was ordered by the physician. .",2015-01-01
10667,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,431,D,0,1,K6RU11,". Based on observation, staff interview, and policy review, the facility failed to discard a vial of insulin after it had been opened greater than thirty (30) days, and failed to develop and implement a written policy that provided directives related to the amount of time vials of insulin may be kept after they are initially opened. This was evident for one (1) resident of sixty-eight (68) residents in the facility who received injectable insulin. Resident identifier: #42. Facility census: 68. Findings include: a) Resident #42 Observation of medication pass, with a nurse (Employee #19) on 09/27/10 at 6:46 a.m., revealed a bottle of Humulin 70/30 insulin with the date of opening marked on the label as 08/26/10. The nurse discarded this bottle and went to the refrigerator, where she retrieved an unopened bottle of insulin. She said they discard all unused bottles of insulin after they have been opened for thirty (30) days. She then dated the new bottle of insulin with the opening date of 09/26/10. She said all of their insulin bottles are kept in the refrigerator when not in use; staff brings out the refrigerated insulins for med pass, as insulin is not stored in the medication carts. Inspection of the discarded bottle of Humulin 70/30 insulin found it was cold to the touch and gave evidence of having been recently refrigerated. During tour of the medication rooms on 09/27/10 at approximately 7:00 a.m., observation found one (1) nearly empty bottle of Novolin-R insulin for Resident #42 in the refrigerator with the open date of 07/18/10. Observation of all other insulin bottles in the refrigerator found them to be either unopened or labeled with dates of less than thirty (30) days after having been opened. During an interview with a nurse (Employee #72) on 09/27/10 at 7:07 a.m., he checked Resident #42's bottle of Novolin-R dated as having been opened on 07/18/10, discarded it, and said insulins are to be kept only thirty (30) days after opening. A new, unopened bottle of Novolin-R insulin was in the refrigerator with her name on it. During an interview with the assistant director of nursing (ADON) on 09/30/10 at 2:00 p.m., she was unable to produce a policy specifying how long to keep opened bottles of insulin, but she said she would look more and have it Monday upon the survey team's return to the facility. On 10/04/10 at approximately 11:30 a.m., the ADON and the director of nursing (DON) produced a one-page copy of a form entitled ""16. STORAGE OF MEDICATIONS"". Section K of this form, related to multiple dose vials, stated: ""Multiple dose vials must be dated and initialed by the nurse when opened to aid the pharmacy consultant in determining stability of the contents. Any drug remaining in the multiple dose vials after 180 days will be discarded according to the facility policy."" The DON said the pharmacy needed to update this policy. During a telephone interview with a local pharmacist on 10/05/10 at 3:00 p.m., she stated all vials of insulin must be discarded after having been opened for twenty-eight (28) days. When asked how long a bottle of Novolin-R may be kept after opening if it remains refrigerated, she stated it could be kept up to ninety (90) days days if continuously refrigerated. .",2015-01-01
10668,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,372,F,0,1,K6RU11,". Based on observation and staff interview, the facility failed to dispose of garbage and refuse properly. The dumpster area was found with trash bags piled high (such that the garbage container could not be covered), and paper, food debris, and other litter was spread on the ground all around the dumpster, creating conditions that could lead to the harborage and feeding of pests. Facility census: 68. Findings include: a) Observation by two (2) surveyors, prior to the noon meal on 09/28/10, found the dumpster to be completely full of garbage bags such that the lids could not be closed. Papers, wrappers, and food debris were scattered completely around the container on the ground. A wooden fence around the dumpster was found to have many holes in the fencing that would not prevent pests from entering the refuse container. This was shown to the consultant dietitian and administrator at approximately 4:15 p.m. on 09/28/10; it was still in the same condition as the previous observation earlier. At 8:15 a.m. on the morning of 09/29/10, observation found the dumpster area still had debris on the ground around the container. .",2015-01-01
10669,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,253,E,0,1,K6RU11,". Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to provide a clean and sanitary environment for the residents of the 100 and 200 halls, by not keeping the hall floors, central shower floors, and/or baseboard heaters clean. This had the potential to affect all residents on these halls. Facility census: 68. Findings include: a) During the general tour at 6:45 a.m. on 09/27/10, this surveyor observed the areas of the floor adjacent to the baseboards of the central hallway, the 100 unit hallway, and the 200 unit hallway to be dirty with a visible build-up of debris. Later, at 1:30 p.m. on 09/27/10, observation of the central shower room on the 200 hall revealed a dirty / discolored tile floor, which was worse around the baseboards. The metal door frames in this room were rusted through at their base, as was the door frame at the entrance of the dish room from the central hall. The baseboard heaters in the 100 hall were visibly full of lent and dust. During an interview with the administrator at 11:00 a.m. on 09/29/10, he accompanied this surveyor to observe all the areas described above and agreed they were not clean. He stated the rusted door frames were scheduled for renovation. The 300 hall had already been renovated and was clean when observed. This renovation was verified by the life-safety code surveyor. .",2015-01-01
10670,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,492,C,0,1,K6RU11,". Based on review of sampled personnel records and staff interview, the facility failed to ensure employees were notified of the Central Abuse Registry in accordance with WV Code 15-2C-2 for five (5) of five (5) personnel records reviewed. Facility census: 68. Findings include: a) A review of five (5) sampled employees' personnel records, conducted with an administrative assistant (Employee #29) on the afternoon of 10/04/10, found each personnel record contained a document signed by the employee indicating they had been informed of the Central Abuse Agency. When Employee #29 was asked to provide a copy of the information given to the five (5) sampled employees, she provided a copy of the Nursing Home Licensure Rule (WV Legislative Rule 64-13), not the Central Abuse Registry notice found in WV Code 15-2C-8. .",2015-01-01
10671,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,329,D,0,1,K6RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and review of the drug insert for [MEDICATION NAME] found on the Food and Drug Administration (FDA) website (www.fda.gov), the facility failed to assure the medication regimen of one (1) of twenty-seven (27) Stage II sample residents free from drugs for which the resident had a known allergy. Resident identifier: #12. Facility census: 68. Findings include: a) Resident #12 Review of Resident #12's medical record found that [MEDICATION NAME] was documented on the resident's list of known allergies [REDACTED]. The medical record contained documentation to reflect the resident had been ordered and received [MEDICATION NAME] 250 mg twice-a-day (BID). Review of the manufacturer's information for [MEDICATION NAME], found on the FDA's website, revealed [MEDICATION NAME] is metabolized by the body into [MEDICATION NAME] and Phenylethylmalonamide (PEMA). Under ""Contraindications"", the manufacturer stated: ""... [MEDICATION NAME] is contraindicated in... 2) patients who are hypersensitive to [MEDICATION NAME]."" The physician was notified on the afternoon of 09/30/10, and ordered the [MEDICATION NAME] tapered and discontinued. .",2015-01-01
10672,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,428,D,0,1,K6RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and review of the drug insert for Primidone found on the Food and Drug Administration (FDA) website (www.fda.gov), the facility failed to assure the consultant pharmacist identified and reported all drug irregularities to the attending physician and the director of nursing for one (1) of twenty-seven (27) Stage II sample resident. Resident identifier: #12. Facility census: 68. Findings include: a) Resident #12 Review of Resident #12's medical record found that Phenobarbital was documented on the resident's list of known allergies [REDACTED]. The medical record contained documentation to reflect the resident had been ordered and received Primidone 250 mg twice-a-day (BID). Review of the manufacturer's information for Primidone, found on the FDA's website, revealed Primidone is metabolized by the body into Phenobarbital and Phenylethylmalonamide (PEMA). Under ""Contraindications"", the manufacturer stated: ""... Primidone is contraindicated in... 2) patients who are hypersensitive to Phenobarbital."" The physician was notified on the afternoon of 09/30/10, and ordered the Primidone tapered and discontinued. The medical record contained no evidence to reflect the consulting pharmacist notified the physician or director of nursing of this irregularity in the resident's medication regimen. .",2015-01-01
10673,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,279,D,0,1,K6RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to develop a comprehensive care plan with quantifiable objectives for the highest level of functioning for two (2) of twenty-nine (29) sampled residents. One (1) resident was observed with contractures of the fingers of the left hand which were not addressed on his plan of care. Another resident experienced a decline in bowel and bladder functioning which was not addressed on the care plan. Resident identifiers: #19 and #13 Facility census: 68. Findings include: a) Resident #19 Observation of Resident #19, during the survey event from 09/27/10 to 10/04/10, revealed the presence of contractures of three (3) fingers on his left hand. During every observation, he held the thumb and forefinger of his left hand in a pincher-type position, with the remaining three (3) fingers bent in toward the palm of his hand. There was no evidence of any skin impairment in the palm as the fingers were not bent in tightly. Due to cognitive impairment, he was unable to follow a command to try to extend those fingers. Review of his care plan revealed the hand splint, which was an intervention found under the goal of preventing skin breakdown, was discontinued in 04/29/09; there was no indication anywhere on the care plan that he had contractures nor was to receive any monitoring or treatment modalities for the contractures. During an interview with a nurse (Employee #44) on 09/29/10 at 2:25 p.m., she said this resident was admitted to the facility after having had a [MEDICAL CONDITIONS], and he had left-sided weakness and a contracture to the left hand from the beginning. She said he used to have splints on the hand, but he would not keep the splints in place and kept taking them off. When asked if he was still getting range of motion to the left arm / hand, she said the nurse aides probably did that during care, and it should be recorded in the aides' ADL (Activities of Daily Living) book. During an interview on 09/29/10 at 3:25 p.m., a nursing assistant (NA - Employee #16) said Resident #19 can extend the outer three (3) fingers of his left hand when he wants to. She said they work with him during his bathing daily to wash between the fingers and move them. Review of the aides' kardex in the ADL book revealed this resident's ""left arm is paralyzed""; and an area for restorative care (which included active or passive range of motion) was not marked to indicate he was to receive these services. During an interview with the director of nursing (DON) and the assistant director of nursing (ADON) on 09/29/10 at 4:15 p.m., they said he used to have a splint for probably a couple of years or so, but it was discontinued last year, because he would no longer use it and kept taking it off. They agreed he had contractures of the left hand, and the ADON said it involved the fingers of the left hand. During a subsequent interview on 09/30/10 at 11:45 a.m., the DON and ADON agreed he had had the contracture for a long time. The DON produced a physical therapy treatment plan dated 05/2005, with the reason for the consult being a left hand contracture post-[MEDICAL CONDITION]. They said they could not find any physician orders [REDACTED]. They said they had spoken with the occupational therapist today and he did not feel this resident would improve. The DON said they moved the resident's fingers while he was asleep and found they could passively move them to open up to about the 50% level, and he did not awaken while they did this. When asked if range of motion might keep him from declining further (whereby his fingers might eventually press into his palm and produce pressure problems), the DON agreed it might potentially prevent further decline, although it was not known for certain. During an interview with the occupational therapist on 10/04/10 at 11:00 a.m., he said therapy assesses this resident quarterly and monitors for early signs of joint involvement changes. He spoke his belief that this resident had met his maximum potential for functionality in the left hand and fingers. Review of the resident's care plan did not reveal any indication of the contractures; any level of impairment in range of motion ability; the need for continued monitoring by nurses and therapy; any plan to try to prevent decline in range of motion ability; nor of the resident's resistance to preventative measures. . b) Resident #13 The resident was admitted with the following Diagnoses: [REDACTED]. A review of his previous annual comprehensive assessment, with an assessment reference date (ARD) of 08/06/09, found he was occasionally incontinent (""2"") of bowel and completely incontinent (""4"") of bladder. An abbreviated quarterly assessment, with an ARD of 11/05/09, revealed he was frequently incontinent (""3"") of bowel. An abbreviated quarterly assessment, with an ARD of 05/06/10, indicated he was totally incontinent (""4"") of bowel continence. His most recent comprehensive annual assessment, with an ARD of 08/05/10, indicated he remained totally incontinent (""4"") of bowel. A review of the resident assessment protocol (RAP) summary documentation associated with the 08/05/10 assessment found: ""Incontinence RAP triggered due to resident having incontinent problem. Resident has no awareness of need to void complicated by resident has diabetes, inability to fully do self care very dependent on staff for care."" The incontinence RAP did not address the resident's decline in bowel continence. A physical therapy progress note, dated 01/28/10, stated, ""Resident has been referred for therapy screen triggering with a decrease in the ability to move in and around her room. Restorative indicates that the resident is difficult to motivate to do any more than she has to. Resident is up and participates in activities daily."" An interview with a licensed practical nurse (LPN - Employee #45), on 09/29/10 at 2:10 p.m., revealed Resident #13 would refuse to go to the bathroom during a period of time that she began to mentally deteriorate. She stated the staff had tried to take her to the bathroom, but the resident did not want to use the bathroom. An interview with a registered nurse (RN - Employee #66) and a social worker (Employee #63), on 09/29/10 at 2:15 p.m., revealed the resident's care plan did not address the decline in her bowel continence. The resident did not want to go to the bathroom, actually refusing to go when she needed to have a bowel movement. She liked to go to activities; but other than going out to activities, she liked to stay in bed and work puzzles and crochet. .",2015-01-01
10674,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,285,D,0,1,K6RU11,"**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 needs of a new resident had been evaluated prior to admission to the facility, to determine whether the resident required specialized services under the Pre-Admission Screening and Resident Review (PASRR) program, for one (1) of twenty-seven (27) Stage II sample residents. Resident identifier: #14. Facility census: 68. Findings include: a) Resident #14 A review of the closed record revealed Resident #14 had been admitted to the facility on [DATE], but the Level II evaluation (to determine whether the resident required specialized services) was not completed until 05/04/10. During an interview with the director of nursing (DON) and the assistant director of nursing (ADON) at 4:00 p.m. on 10/04/10, they were notified of this finding with no additional information provided prior to the survey exit date. .",2015-01-01
10675,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,272,D,0,1,K6RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to accurately encode on the minimum data set (MDS) the presence of contractures for one (1) of twenty-seven (27) Stage II sample residents. Resident identifier: #19: Facility census: 68. Findings include: a) Resident #19 Observation of Resident #19, during the survey event from 09/27/10 to 10/04/10, revealed the presence of contractures of three (3) fingers on his left hand. During every observation, he held the thumb and forefinger of his left hand in a pincher-type position, with the remaining three (3) fingers bent in toward the palm of his hand. Due to cognitive impairment, he was unable to follow a command to try to extend those fingers. Medical record review revealed he entered the facility several years ago following a [MEDICAL CONDITIONS] with left-sided weakness. Medical record review going back to 2005 revealed the presence of a contracture of the left hand resulting from that [MEDICAL CONDITION]. Review of resident's most recent MDS, an abbreviated quarterly assessment with an assessment reference date of 07/01/10, found no coding for any contractures; rather, the assessor recorded ""0"" (""none"") in Section G4c for ""functional limitation in range of motion"" and ""0"" (""none"") in Section S3 for contractures. During an interview with the director of nursing (DON) and the assistant director of nursing (ADON) on 09/30/10 at 11:45 a.m., they agreed Resident #19 has had the contracture for a long time and stated the MDS was in error. The DON produced a physical therapy treatment plan dated 05/2005, with the reason for the consult being a left hand contracture post-[MEDICAL CONDITION]. During an interview with the occupation therapist on 10/04/10 at 11:00 a.m., he stated his belief that Resident #19 had reached his maximum potential of functionality of the left hand and fingers and he continues to receive quarterly therapy assessments to monitor for any changes in the condition. .",2015-01-01
10676,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,466,F,0,1,K6RU11,". Based on staff interview and policy review, the facility failed to develop a policy / procedure to ensure the availability of potable water in the event of an emergency. This has the potential to affect all residents. Facility census: 68. Findings include: a) During an interview on the mid-morning of 10/04/10, the dietary manager (Employee #68) was asked about the availability of potable water (safe to drink) in the event of an emergency. Employee #68 stated the facility had an agreement with a local vendor that would bring water to the facility should their normal water supply be interrupted or unavailable for any reason. Interviews with the director of nursing (DON - Employee #15) and administrative assistant (Employee #29), on 10/04/10 at 1:00 p.m., revealed they were not aware of any policy or written procedure discussing how potable and non-potable water would be made available to the facility in the event of water outage or emergency. Review the facility's emergency disaster preparedness manual, on the early afternoon of 10/04/10, found no evidence of a written policy or procedure that was available for all staff to address how to provide water for residents in the case of an emergency. .",2015-01-01
10677,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,323,E,1,0,G2W911,". Based on observation and staff interview, the facility failed to provide supervision to prevent avoidable accidents and to promote resident safety, as evidenced by staff leaving a medication cart in the hallway unlocked and unattended. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 126. Findings include: a) Observation, on 09/27/11 at 9:21 a.m., found a medication cart unlocked and unattended by staff. The door to the resident rooms were closed. The nurse responsible for the medication cart could not be found. Interview with Employee #49 (a licensed practical nurse), at 9:30 a.m., confirmed she had left the cart unlocked and unattended while she was in the room with a resident with the door closed. .",2015-01-01
10678,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,328,D,1,0,G2W911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure residents received oxygen therapy as ordered by the physician for two (2) of fifteen (15) sampled residents. Resident identifiers: #36 and #74. Facility census: 126. Findings include: a) Resident #36 During random observations of residents, on 09/26/11 at 3:45 p.m., found Resident #36 in his room with oxygen in use. The flow rate on the oxygen concentrator was set to 3 liters per minute. Resident #36's son was present at the time of the discovery. Review of the medical record revealed Resident #36's oxygen was to be delivered at a rate of 2 liters per minute. This observation was reported to the registered nurse (RN - Employee #42), who stated, ""He's supposed to be on 2 liters not 3."" Employee #42 changed the settings on the concentrator to 2 liters as ordered. Observation, on 09/27/11 at 2:19 p.m., found Resident #36 with the nasal cannula in place, but the oxygen concentrator was not running. This observation was reported to an assistant director of nursing (ADON - Employee #90) at 2:19 p.m., who stated, ""It's out of oxygen."" -- b) Resident #74 Observation, on 09/26/11 at 3:00 p.m., found Resident #74 in her room with her oxygen concentrator running, but the nasal cannula was lying in her bed. A nursing assistant was observed in the room at that time. A repeat observation at 3:15 p.m. found Resident #74 with her nasal cannula in place and the flow rate of the oxygen concentrator running at 5 liters per minute. Resident #74's nurse, a licensed practical nurse from a temporary staffing agency (Employee #146) was asked how much oxygen the resident was to be receiving. She stated, ""It's supposed to be on 3 liters."" Review of Resident #74's medical record found a physician's orders [REDACTED]. Employee #146 returned to this surveyor later in the day and stated, ""I read her chart and she is supposed to be on 2 liters not 3. I don't take care of her a lot."" .",2015-01-01
10679,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,246,D,1,0,G2W911,". Based on observation, resident comments, and staff interview, the facility failed to ensure water was readily available and easily accessible to one (1) resident of random opportunity. Resident identifier: #5. Facility census: 126. Findings include: a) Resident #5 During random observations of residents, on 09/27/11, found Resident #5 hollering for a nurse. This surveyor entered the room and noted the resident's water pitcher was located on her overbed table, which was at the foot of her bed. The resident asked the surveyor to move her overbed table so she could reach it, stating, ""I want a drink of water."" The water pitcher was empty. This observation was immediately reported to the registered nurse (Employee #42). .",2015-01-01
10680,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-09-13,152,D,1,0,8CVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the medical record and staff interview, the facility failed to assure documentation was obtained to verify who had authority to make health care decisions on behalf of the resident. On numerous occasions throughout the medical record of Resident #56, the facility referred to the resident's daughter as the resident's medical power of attorney representative (MPOA) and allowed her to make medical decisions for the resident; however, the medical record failed to contain any documentation showing the resident had designated the daughter as his MPOA. Furthermore, the facility also failed to obtain an evaluation of the resident's capacity to understand and make informed health care decisions when it was determined the resident had severe cognitive impairment. This was true for one (1) of ten (10) sampled residents. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Further review of the medical record found an admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 02/13/11. The results of the brief interview for mental status (BIMS) contained in this MDS revealed a score of ""5"", indicating the resident's cognitive performance was severely impaired. A quarterly MDS, with an ARD of 07/28/11, revealed a BIMS score of ""9"", indicating the resident's cognitive performance was moderately impaired. (A BIMS score of ""0"" to ""7"" indicates severely impaired cognitive performance; a score of ""8"" to ""12"" indicates moderately impaired cognitive performance; and a score of ""13"" to ""15"" indicates a resident is cognitively intact.) The medical record contained no further documentation to reflect the facility had assessed the resident's cognitive status. The medical record also contained no documentation to reflect the physician had completed an assessment of the resident's capacity to make medical decision when the facility became aware of the resident's severely impaired cognitive performance as indicated by the results of the BIMS on 02/13/11. Further review of the medical record revealed an absence of documentation to reflect the resident had ever designated his daughter to serve as his MPOA. Additionally, there was no evidence to reflect the physician had appointed the daughter to serve as the resident's health care surrogate after having made a determination that the resident was unable to make his own informed health care decisions. On numerous occasions throughout the resident's stay the resident's daughter had been contacted and had been allowed to make medical decisions for the resident. The following are some examples of such occasions: - On 02/09/11, the daughter completed the admission agreement which dictated the responsibilities of the resident and facility as terms for the condition of the stay. - On 04/09/11, nursing staff had referred to the daughter as ""MPOA"" when she was called concerning the resident's new orders. - On 05/10/11, the daughter had been allowed to determine the resident should not endure surgical procedure for a hernia. - On 08/15/11, the daughter had been allowed to decide whether the resident could attend an appointment for an eye exam. - The daughter was listed as the contact person for the resident on the admission information. - A grievance / concern form, completed by the corporate social worker on 05/11/11, referred to the resident's daughter as the ""MPOA"". From all indications, the facility's staff believed the daughter was the resident's MPOA and contacted her to make medical decisions for the resident during his stay at the facility. During an interview with the director of nursing (DON) on the afternoon of 09/12/11, she was unable to locate documentation to prove the resident's daughter was legally appointed to serve as his health care decision maker. She verified the resident's capacity should have been evaluated by the resident's physician but could find no evidence this had been completed. On the morning of 09/13/11, the DON provided a capacity statement completed by the resident's physician on 09/12/11. The physician had determined the resident lacked capacity to make medical decisions due to early dementia and the lack of inability to process information. The physician also provided a written statement, dated 09/13/11, which contained the following information: ""(name of resident) was admitted to (name of facility) in February of 2011. I am confident that I did a Determination of Capacity at that time and that he was deemed incompetent."" In summary: The facility failed to produce an evaluation of the resident's capacity to make health care decisions when they knew (or should have known) the resident had cognitive impairment. Further, the facility failed to verify that the daughter, who was allowed to make health care decisions, was the legally appointed individual designated to make medical decisions on behalf of the resident. .",2015-01-01
10681,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-09-13,166,D,1,0,8CVP11,". Based on review of the facility's grievance / concern forms, medical record review, and staff interview, the facility failed, after receiving a complaint / grievance, to make prompt efforts to resolve the grievance and to apprise the resident / family of progress toward resolution. On 05/11/11, the daughter of Resident #56 alleged the resident was missing his hearing aids and an IPOD (a portable media player). The facility addressed the missing hearing aids but failed to identify how they would address and resolve the grievance concerning the missing IPOD. This was true for one (1) of ten (10) records reviewed. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Review of the facility's grievance / concern forms revealed a grievance received on 05/11/11 from Resident #56's daughter. The concern was described as follows: ""Spoke with POA (power of attorney) via telephone regarding hearing aids that were lost sometime near his admitted . This SW (social worker) spoke with patient who validated this complaint. POA also voiced that IPOD is missing - was a larger (older model) grayish is color."" The actions taken to resolving this concern were: ""Provided 'listening ears' temporarily to patient while awaiting audiology appt. (appointment) & fitting for replacement hearing aids."" In response to the question ""Was the grievance / complaint resolved?"" was written: ""Provided 'listening ears' and patient does not utilize. Pt. (patient) given appt with (name of company to provide exam) June 29th. Will attempt to arrange sooner appt."" The grievance concern form was signed by the corporate social worker on 05/13/11. There was no documentation on this form as to the status of the missing IPOD or the facility's plans to address / resolve that concern. The documentation provide on the grievance/concern form addressed only the missing hearing aids. Further review of this grievance / concern form revealed the following documentation from Employee #57, a newly hired social worker, on the back of the grievance / concern (dated 06/22/11): ""This social worker contacted (name of daughter) to remind her of (name of company to conduct audiology exam) coming in on June 29th to evaluate and replace hearing aid. In regards to the IPOD missing (name of daughter) does not wish for us to replace it at this time. She has replaced it herself and has asked nursing to keep it locked up at night."" During an interview with Employee #57 at approximately 11:45 a. m.. on 09/12/11, she stated she had called the daughter on 06/23/11 to follow up on the grievance / concern voiced by the daughter on 05/11/11. Employee #57 verified she was not employed at the time the initial grievance was made on 05/11/11. She was unable to provide any evidence to reflect efforts by the facility to search for the missing IPOD or any evidence the daughter was contacted and advised of the status of the IPOD before her call on 06/23/11. On 09/13/11 at approximately 11:45 a.m., the grievance was discussed with the facility's administrator and director of nursing. No further information was provided. The purchase of a new IPOD by the resident's daughter did not eliminate the facility's responsibility to address the missing IPOD when they became aware on 05/11/11 and to provide prompt feedback to the daughter as to the facility's plan for the resolution of the grievance.",2015-01-01
10682,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-09-27,280,D,1,0,5CPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plan for one (1) of six (6) sampled residents, after she returned from an inpatient psychiatric treatment facility following an attempt to harm her roommate. She readmitted to the facility for Medicare-covered skilled services for observation of behaviors and medication changes, yet there was no revision to the resident's care plan to ensure she received adequate supervision to prevent injury to herself and to others. Resident identifier: #62. Facility census: 60. Findings include: a) Resident #62 Record review revealed Resident #62, an [AGE] year old female whose [DIAGNOSES REDACTED]. Her behaviors included wandering into other residents' rooms, hitting other residents and staff, exposing herself to others, and engaging in verbally abusive behaviors towards others. According to her medical record and staff interviews, she had problems relating in a positive manner to every roommate with whom she had been cohorted. - A nursing note, on 06/23/11 at 19:20 (7:20 p.m.) stated (quoted as typed): ""Resident found in her room over her roommate. She had taken the roommates O2 (oxygen) tubing from her nose and had a pillow over her head. POA (power of attorney) notified of [MEDICATION NAME] 25mg Im (via intramuscular injection) x 1 dose now and transfer to (local hospital) for eval (evaluation). DON (director of nursing) was notified. Dr. (name) was notified."" A subsequent entry, on 06/24/11 at 18:35 (6:35 p.m.) stated the local hospital was transferring Resident #62 to another hospital with an inpatient psychiatric unit. Resident #62 remained on the psychiatric unit until she returned to the facility on [DATE]. - The discharge instructions / continuing care plan from the psychiatric unit hospital was reviewed. This instruction sheet stated the following under the heading ""Proposed intervention / follow up of problem(s) still evident at the time of discharge"": 1. Management of signs and symptoms of agitation. 2. Management of medications compliance and medication treatment. 3. Reorient and redirect the patient with distraction of food and beverage."" The resident was readmitted to the facility on [DATE] under Medicare-covered skilled services for which she was to be monitored for behaviors and the effectiveness of her medications. - The resident's care plan (last reviewed on 06/04/11) contained the following problem statement (quoted as typed): ""Resident exhibits physical aggression as evidenced by hitting other residents and staff, wandering into other residents rooms and hitting them. She also has had other inappropriate behavior: exposing herself to other residents."" The goal associated with this problem statement was (quoted as typed): ""Resident will have not more than 1 episode of hitting others, wandering into others rooms, exposing herself per week times 90 days."" The interventions included (quoted as typed): ""Allow time to vent feelings / needs. Approach resident in a calm friendly manor. Assess and manage unmet needs such as: pain, toileting, fatigue and hunger. Divert resident by giving alternative objects or activity. Encourage family involvement. Listen to resident's needs and adjust plan as appropriate. Listen to the resident and try to calm. Maintain as consistent of a routine as possible and utilize consistant caregivers. Remove resident from enviornment. Notify MD when aggressive behavior occurs as resident has history of frequent UTI's (urinary tract infections) which causes resident to behave oddly. administer meds as ordered. Identify self with each interaction and purpose of visit. Redirect and provide reminders as needed. Encourage daily decision making by providing the resident with options that she can choose from. Provide simple, clear directions for task."" There was no evidence to reflect the care plan for this resident's physical aggression towards others had been reviewed and revised by the facility's interdisciplinary team upon Resident #62's return from the psychiatric unit on 07/18/11, to include the provision of staff supervision to promote safety of the resident and others. - During an interview on 09/27/11 at 9:30 a.m., the social worker (Employee #11) identified that she wrote the behavior care plans. She verified that no interventions had been added to the care plan for the resident's physical aggression towards others upon Resident #62's return from the psychiatric unit. - A nursing note dated 07/25/11 at 10:10 stated (quoted as typed), ""This nurse and RN (registered nurse) entered resident's room after hearing resident (Resident #62's roommate) yelling 'get her off me!' Resident standing behind (roommate's) w/c (wheelchair). (Roommate) stated that (Resident #62) was 'pulling and tugging on my wheelchair' (Roommate) also stated that resident hit her right arm. (Resident #62) stated 'none of your business' when asked what she was doing. Redirected resident back to her bed. No apparent injury to either resident."" A subsequent nursing note dated 07/25/11 at 18:15 (6:15 p.m.) stated (quoted as typed), ""... This nurse and RN called to C-wing. Resident noted laying on floor on right side. CNS stated that (a male resident) stated resident entered his room and struck him. (The male resident) then struck resident back causing her to fall and hit floor."" Resident #62 was transferred to the local hospital, where she was diagnosed with [REDACTED]. .",2015-01-01
10683,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-09-27,323,G,1,0,5CPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide adequate supervision to promote resident safety, resulting in physical harm to one (1) of six (6) sampled residents. Resident #62 had a [DIAGNOSES REDACTED]. Her behaviors included wandering into other residents' rooms, hitting other residents and hitting staff, and engaging in verbally abusive behaviors towards others. On the evening of 06/23/11, she was observed holding a pillow over her roommate's face, after which she was transferred to local hospital on the evening of 06/23/11, and subsequently admitted to an inpatient psychiatric unit at a second hospital on [DATE]. When she returned to the nursing facility on 07/18/11, the facility's interdisciplinary team failed to review and revise her care plan with interventions such as increased staff supervision, to promote the safety of this resident and others because of her behaviors. On 07/25/11, Resident #62 wandered into the room of a male resident and hit him. The male resident hit her back, causing her to fall and sustain a fractured hip. Resident identifier: #62. Facility census: 61. Findings include: a) Resident #62 1. Record revealed Resident #62 was an [AGE] year old female who was originally admitted to this facility on 07/28/06. Her [DIAGNOSES REDACTED]. Further record review revealed, in December 2010, this resident exhibited signs and symptoms of psychosis and was transferred to a hospital's inpatient psychiatric unit for evaluation and treatment. According the hospital's discharge summary, her symptoms included the following (quoted as typed): ""Restless behaviors like pacing and continually fingering certain object has increased. (Resident #62) cannot organize thoughts or following logical explanations. (Resident #62) becomes agitated and may hit, kick, bite, scream or grab. ... There are indications that (Resident #62) is hallucinating."" Her treatment while on the inpatient unit consisted of medication adjustment, and she returned to the facility on [DATE]. -- 2. Review of nursing notes following her return to the facility after this inpatient psychiatric stay revealed the following entries (all quoted as typed): - 01/14/11 at 17:03 (5:03 p.m.) - ""... was removed from another residents room she had been browsing thru residents things assisted resident into her own room ..."" - 01/15/11 at 10:58 - ""CNA (certified nursing assistant) (name), reported to this nurse that resident shut door this am (morning). When CNA opened door, resident was standing beside roommate's bed looking at her. This cont'd (continued) one more time. CNA explained to resident that door needed to remain open and to not bother roommate. Resident pleasantly confused but complied and layed back down in bed to watch tv ..."" - 01/28/11 at 13:20 (1:20 p.m.) - ""... CNA (name) reported that resident was standing over her room mate this am (morning) causing room mate to be agitated. (Name of CNA) also reported that resident was taking belongings off of window seal and placing them in roommate's bed. ... "" - 02/11/11 at 13:04 (1:04 p.m.) - ""... Wandering in hallways and in resident's rooms this shift. Staff cont's (continues) to redirect resident. ... "" - 02/16/11 at 08:03 - ""(Name) CNA reported to this nurse that resident was standing in doorway of another resident naked. (Name) explained that she attempted to redirect resident and (Resident #62) stated 'she wanted my clothes so I gave them to her.' Resident was clothed and redirected back to room without difficulty. "" - 02/16/11 at 14:35 (2:35 p.m.) - ""Resident came into this my office and was carrying a blue cup that she was drinking from. She sat it down on my desk and was saying something to me that was nonsensicle. She then proceed to go over to the arm chair and began removeing her pull up brief like she was going to use the restroom. ... I assisted her to her room and led her to the restroom. ... When I went back into my office, I noticed that the cup that she had been drinking from earlier contained tobacco and tobacco spit from another resident. Her nurse was immediately notified and she is to notify the physician. ... "" - 02/17/11 at 05:15 - ""Entered resident room to administer marinol (an appetite stimulant) - attempted to give resident a drink after pill placed in mouth. She slapped me and mumbled completely nonsensical words. I then poured the water into a cup thinking that resident could not drink from a straw D/T (due to) increased confusion. When I attempted to give resident a drink form the cup she grabbed my wrist and the cup in a combative manner causing the water to spill on herself. CNA (name) entered the room and stated that resident had slapped her on the side of the head earlier while they were doing bedcheck. "" - 02/26/11 at 07:40 - ""CNA reported to this nurse that while attempting to feed resident breakfast, resident slapped CNA on leg. CNA stated to resident that she was not allowed to hit people. Resident then stated 'We'll see.' CNA then explained to this nurse that she stopped feeding resident and switched places with another CNA to see if resident calmed down. Resident then began trying to slap again. ... "" - 02/27/11 at 00:36 (12:36 a.m.) - ""Asleep in bed at this time, noted to be oob (out of bed) at 11:30 pm and standing over her roommate. Bed alarm on, under pillow. Res. (resident) assisted to bed and alarm repositioned. ... "" - 03/14/11 at 22:30 (10:30 p.m.) - ""Resident's alarm noted to be sounding. This nurse entered resident's room and resident was sitting on side of roommates bed, playing with the call light. Resident's roommate was in no distress, however this woke the roommate. ... This nurse assisted resident over to her side of the room ... "" - 05/26/11 at 22:15 (10:15 p.m.) - ""CNA notified the nurse that resident was hitting resident (Resident #62's roommate) in her room. I came to doorway and witnessed resident hitting resident ... two times in the head with her open hand."" Her roommate was moved to another room, and Resident #62 calmed down after the move. - 05/27/11 at 10:00 - A licensed practical nurse (LPN) observed Resident #62 going across the hallway from her room and exposing herself. - 06/14/11 at 18:01 (6:01 p.m.) - ""(Resident #62) is upset because of the new residnet in her room. she want to residnet out of her room. (Resident #62) is over to her roomate and telling her to get out of her room. "" - 06/14/11 at 21:29 (9:29 p.m.) - (Resident #62) is upset and want her roommate out of her room, (Resident #62) state she needs to clean her room and can not clean it with the other resident in her room. She is over to her room mate bed and trying to get her out of her room. i re directed (Resident #62) and brought her to the nurses station to talk to the nurses."" - 06/14/11 at 05:41 - ""(Resident #62) was up all night trying to help her roommate, wanting her to get out of bed so (Resident #62) can clean the room. (Resident #62) was over on her roommate side of the bed touching all her belonging and trying to get her roommate a drink and spilling her drink on the roommate. "" - 06/15/11 at 05:44 - ""(Resident #62) is upset and want the lady her roommate out of her room. "" - 06/15/11 at 10:37 - ""Resident is being observed for mood / behaviors. Resident received new roommate on 6/14/11 and is upset about this. She was noted several times last night hovering over her roommate and stating 'get out of my room'. It was reported per CNA that resident was kissing a male resident on the mouth two days ago ... "" - 06/18/11 at 10:47 - ""Behavior changes Blood test completed on 6/17/11 Been trying to obtain a U/A for 2 days unable to obtain. Resident in restroom was calm at the time I placed her in the restroom. A CNA was helping her change her brief the CNA was bend over and (Resident #62) hit the CNA in the back of the head with a shoe. ..."" - 6/18/11 at 18:34 (6:34 p.m.) - ""(Resident #62) pacing the hallway going up to Dinning room and returning to room many times this evening. Going over to her room mate and touching her roommate belongings. Sitting on her roommate bed, wanting her roommate to get out of the room so she can clean the room."" - 06/22/11 at 11:18 - ""... Mood varies. continues to have episodes of wandering, and continues to be confused."" - 06/23/11 at 13:24 (1:34 p.m.) - ""... Resident cont's to get up and hover over room mate and touch her belongings. Staff cont's to redirect. ..."" - 06/23/11 at 19:20 (7:20 p.m.) - ""Resident found in her room over her roommate. She had taken the roommates O2 (oxygen) tubing from her nose and had a pillow over her head. POA (power of attorney) notified of Haldol 25mg Im (via intramuscular injection) x 1 dose now and transfer to RGH (local hospital) for eval (evaluation). DON (director of nursing) was notified. Dr. (name) was notified."" A subsequent entry, on 06/24/11 at 18:35 (6:35 p.m.) stated the local hospital was transferring Resident #62 to another hospital with an inpatient psychiatric unit. Resident #62 remained on the psychiatric unit until she returned to the facility on [DATE]. -- 3. The discharge instructions / continuing care plan from the psychiatric unit hospital was reviewed. This instruction sheet stated the following under the heading ""Proposed intervention / follow up of problem(s) still evident at the time of discharge"": ""1. Management of signs and symptoms of agitation. 2. Management of medications compliance and medication treatment. 3. Reorient and redirect the patient with distraction of food and beverage."" The resident was readmitted to the facility on [DATE] under Medicare-covered skilled services for which she was to be monitored for behaviors and the effectiveness of her medications. -- 4. The resident's care plan (last reviewed on 06/04/11) contained the following problem statement (quoted as typed): ""Resident exhibits physical aggression as evidenced by hitting other residents and staff, wandering into other residents rooms and hitting them. She also has had other inappropriate behavior: exposing herself to other residents."" The goal associated with this problem statement was (quoted as typed): ""Resident will have not more than 1 episode of hitting others, wandering into others rooms, exposing herself per week times 90 days."" The interventions included (quoted as typed): ""Allow time to vent feelings / needs. Approach resident in a calm friendly manor. Assess and manage unmet needs such as: pain, toileting, fatigue and hunger. Divert resident by giving alternative objects or activity. Encourage family involvement. Listen to resident's needs and adjust plan as appropriate. Listen to the resident and try to calm. Maintain as consistent of a routine as possible and utilize consistant caregivers. Remove resident from enviornment. Notify MD when aggressive behavior occurs as resident has history of frequent UTI's (urinary tract infections) which causes resident to behave oddly. administer meds as ordered. Identify self with each interaction and purpose of visit. Redirect and provide reminders as needed. Encourage daily decision making by providing the resident with options that she can choose from. Provide simple, clear directions for task."" There was no evidence to reflect the care plan for this resident's physical aggression towards others had been reviewed and revised by the facility's interdisciplinary team upon Resident #62's return from the psychiatric unit on 07/18/11, to include the provision of staff supervision to promote safety of the resident and others. -- 5. A nursing note dated 07/25/11 at 10:10 a.m. stated, ""This nurse and RN (registered nurse) entered resident's room after hearing resident (Resident #62's roommate) yelling 'get her off me!' Resident standing behind (roommate's) w/c (wheelchair). (Roommate) stated that (Resident #62) was 'pulling and tugging on my wheelchair' (Roommate) also stated that resident hit her right arm. (Resident #62) stated 'none of your business' when asked what she was doing. Redirected resident back to her bed. No apparent injury to either resident."" A subsequent nursing note dated 07/25/11 at 18:15 (6:15 p.m.) stated, ""... This nurse and RN called to C-wing. Resident noted laying on floor on right side. CNS stated that (a male resident) stated resident entered his room and struck him. (The male resident) then struck resident back causing her to fall and hit floor."" Resident #62 was transferred to the local hospital, where she was diagnosed with [REDACTED]. -- 6. During an interview with the DON on 09/26/11 at 2:00 p.m., when questioned about the resident's care plan and lack of interventions to ensure Resident #62's safety and the safety of others, she stated this resident did not really wander into other residents' rooms - that her behaviors were directed towards her roommates. - During an interview with Employee #46 at 10:40 a.m. on 09/27/11, she verified that she was a CNA who had provided care for Resident #62. Employee #46 stated she would see Resident #62 wander into other residents' rooms and bother their things, and she would have to redirect her. She stated that, at one time, they had a bed alarm on her, but she would take it off and hide it. She described this alarm as the type that would be clipped on to the resident's clothing. She could not recall any other type of alarm being tried on this resident. Employee #46 verified that other residents complained frequently about Resident #62. When questioned about what special instructions she was given about this resident when she returned from the psychiatric unit, Employee #41 said they told the nursing assistants to keep a close eye on her. - During an interview with Employee #49 on 09/27/11 at 11:00 a.m., she verified that she was a CNA who had been employed at this facility for eighteen (18) years. When questioned about when Resident #62 tried to hurt her roommate, Employee #49 reported Resident #62 exhibited these behaviors anytime she had a roommate. When questioned about special instructions she was given about this resident when she returned from the psychiatric unit, Employee #49 stated they were not given any special instructions - they were just told to watch her. - During an interview with Employee #41 on 09/27/11 at 4:30 p.m., she verified that she was an evening shift CNA. When questioned about Resident #62, Employee #41 stated she often wandered in other residents' rooms. She reported that Resident #62 still had issues with her roommate when she returned from the psychiatric unit, but it was a different roommate than she had before she left. Resident #62 would tell her to move her stuff, that this was her room when it was on her roommate's side of the room. Employee #41 reported that Resident #62 was no different when she returned from the psychiatric unit than she was prior to going. When questioned about special instructions she was given about this resident when she returned from the psychiatric unit, Employee #41 said she could not recall any instructions provided that were different than prior to her transfer to the hospital for attempting to hurt another resident. - During an interview with Employee #60 on 09/27/11 at 4:35 p.m., she verified that she was a CNA who had provided care for Resident #62. Employee #60 stated this resident got up independently and wandered down the hall into other residents' rooms and that other residents frequently complained about her bothering their things. When questioned about what special instructions she was given about this resident when she returned from the psychiatric unit, Employee #60 stated they were not given any different instructions for her care. -- 7. During an interview on 09/27/11 at 9:30 a.m., the social worker (Employee #11) identified that she wrote the behavior care plans. She verified that no interventions had been added to the care plan for the resident's physical aggression towards others upon Resident #62's return from the psychiatric unit.",2015-01-01
10684,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-11-23,371,F,1,0,5CPP12,"Based on observation, policy review, and staff interview, the facility failed to prepare and store food under sanitary conditions. This deficient practice had the potential to affect all residents residing in the facility on an oral diet. Facility census: 60. Findings include: a) During random observations of the resident dining area, at 2:30 p.m. on 11/21/11, a member of the dietary department (Employee #78) was observed opening large bags of cereal and placing them into a plastic bin. She was noted to attempt to pull apart the top of one large bag of cereal. She made several unsuccessful attempts, when she was observed to grasp the top of the bag with her teeth and tear it open. She then poured the cereal past the opening she had made with her teeth. The dietary manager (Employee #8) was informed of the observation. She instructed the employee to discard the contaminated cereal and provided training on the appropriate way to open bags of cereal. b) A tour of the large cooler in the dietary department, on 11/21/11 at 4:45 p.m., found raw turkey products stored on a shelf over a box of raw vegetables which included an opened bag of celery, a large bag of cucumbers, and a large bag of yellow squash. c) During the observations of the evening meal service, on 11/21/11 at 5:00 p.m., the cook, (Employee #74) was serving residents from a buffet type setting in the dining room. She was asked to provide the written food temperatures taken for that meal. Employee #74 stated that the ""paper"" was not there to record food temperatures. She was asked how long she had not written down food temperatures. She stated it had been approximately two (2) weeks. The dietary manager, Employee #8, provided the policy related to recording food temperatures on at 9:40 a.m. 11/22/11. The policy, entitled ""FOOD AND NUTRITION SERVICES PRODUCTION SHEET INSTRUCTIONS"", item #20, found the following language, ""At the beginning of the meal service, holding temperatures are taken and recorded for each item. . . ."" The dietary manager, Employee #8, agreed staff should have been recording food temperatures.",2015-01-01
10685,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,356,C,0,1,DBCB11,"Based on observation and staff interview, the facility failed to ensure the daily nursing staffing posting was in compliance with the posting requirement set forth by section 941 of BIPA (benefits improvement and protection act) specified as sections 1819 (b)(8) and 1919 (b) (8) of the act. This practice has the potential to affect both residents and visitors to the facility. Facility census: 81. Findings include: a) On 07/01/09 at approximately 4:00 p.m., observation of the facility's nursing staff form, posted in the hallway of the first floor, revealed the facility had not updated the form to reflect the number of licensed / unlicensed nursing staff working on the evening shift. In addition, the facility did not have the total number of actual hours worked each day by nursing staff who were directly responsible for resident care. The director of nursing, when informed of the issue on 07/01/09 at approximately 4:30 p.m., indicated she was having a meeting the the nurse who was responsible for updating the staffing sheet on the evening shift. She reported she was unaware the form needed to reflect the total number of hours worked each day by direct care nursing staff.",2015-01-01
10686,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,323,E,0,1,DBCB11,"Based on observation, a review of the material safety data sheets, and staff interview, the facility failed to ensure the locked unit, in which cognitively impaired residents resided, was kept safe and free from accident hazards. The janitor's closet on this unit was left unlocked, allowing access by the residents to its hazardous contents. This practice has the potential to result in more than minimal harm to all residents on this unit (Unit 3-C). Unit census: 17. Facility census: 81. Finding include: a) Unit 3-C During a tour of the locked unit (Unit 3-C) on 06/29/2009 at 2:00 p.m., the door to the janitor's closet was noted to be unlocked. This surveyor opened the door and looked around on the inside. The contents of this closet included heavy duty cleaner, disinfectant, floor cleaner, and Ajax. After the surveyor came out of the closet, a health services worker (Employee #111), who had been standing in the hall and observed the surveyor go into the closet, came and locked the door. She stated, ""He must have forgot to lock the door. He took the residents outside to smoke."" The housekeeping supervisor (Employee #14) was made aware of this observation on 07/01/09 at 10:00 a.m., and she was asked to provided the material safety data sheets (MSDS) for the chemicals observed in the unlocked closet. Review of the MSDS sheets revealed the chemicals in this unlocked closet could be hazardous to the residents if they ingested the products, got the Ajax on the skin, or inhaled the particles. .",2015-01-01
10687,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,279,D,0,1,DBCB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to develop and implement care plans of two (2) of fourteen (14) sampled residents. Resident # 74 was receiving the sedating drug [MEDICATION NAME] for [MEDICAL CONDITION], and the resident had no assessment identifying this problem nor was a care plan developed for [MEDICAL CONDITION]. Resident #39 had a care plan developed for small meals and low caffeine, which was not communicated and implemented. Resident identifiers: #74 and #39. Facility census: 81. Findings include: a) Resident #74 Medical record review revealed this resident was receiving the sedating drug [MEDICATION NAME], 1 mg in the morning and 2 mg at bedtime. During an interview on 07/02/09 at 9:50 a.m., the assistant director of nursing (ADON - Employee #24) revealed this resident was receiving [MEDICATION NAME] to treat [MEDICAL CONDITION] only. Review of the resident's current care plan, provided by the minimum data set assessment (MDS) coordinator on 06/30/09, revealed no plan addressing the problem of [MEDICAL CONDITION]. Review of quarterly MDS assessments, with assessment reference dates of 03/15/09 and 06/14/09, found, in Section E, this resident had not been identified as having sleep-cycle difficulties. In a subsequent interview on 07/02/09 at 10:15 a.m., the ADON confirmed the use of [MEDICATION NAME] was for [MEDICAL CONDITION] only. A comprehensive plan of care had not been developed for this resident with [MEDICAL CONDITION], to include non-pharmacologic interventions to assist to promote sleep and efforts to identify and mitigate causative factors that altered the resident's ability to sleep. b) Resident #39 Review of the interdisciplinary care plan for this resident found a care plan established on 01/13/09, which had been continued and was to be reviewed again on 07/16/09, for gastric pain related to his hiatal hernia and [MEDICAL CONDITION] reflux disease (GERD). The interventions for this problem included: ""Resident to have small meals and snacks several times a day"" and ""Limit caffeine, chocolate, medications that relax sphincter."" The disciplines named to carry out these interventions included the dietary department. Review of the resident's physicians orders revealed the resident received additional fluids on his lunch and dinner tray, he was to have double portions of vegetables with lunch and dinner, and he was to receive two (2) cups of coffee with each meal, as well as a consistent carbohydrate diet. Meal observations, on 06/30/09 and 07/01/09, found the resident received meals consistent with his physician orders. His dietary card, when reviewed, was also consistent with the orders. However, there was no evidence to reflect the care planned interventions for small meals and a limit of caffeine and chocolate had been implemented. The dietary manager (DM), when interviewed on 07/02/2009 at 9:30 a.m., identified this resident did not have orders to receive small meals, and the approaches written on the care plan were not consistent with the dietary care plan. The DM confirmed that, even though there was no evidence the dietary department knew the resident was to have a restriction on caffeine, all residents on the behavior unit were routinely served decaffeinated coffee. .",2015-01-01
10688,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,156,C,0,1,DBCB11,"Based on observation and staff interview, the facility failed to post all complete contact information for all applicable State advocacy agencies as required by the regulation. Only the regional ombudsman's name and contact information were posted for public view. This has the potential to affect all residents as all residents and families are to have access to this information. Facility census: 81. Findings include: a) On 07/01/09 at 2:30 p.m., review of posted contact information of all pertinent State client advocacy groups, observed on the third floor of the facility, revealed only the name, address and telephone number of the regional ombudsman. Phone numbers were listed for other agencies, but not addresses. Discussions with the administrator, on the afternoon of 07/01/09 and again on the morning of 070/2/09, revealed the addresses and phone numbers of the other advocacy groups were not posted in any other locations of the facility as well. The following information was omitted from the public postings: - The contact information for the State survey and certification agency (which is also the State licensure office); - The contact information for the State long-term care ombudsman; - The contact information for the protection and advocacy network; - The contact information for the Medicaid fraud control unit; and - A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. .",2015-01-01
10689,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,246,D,0,1,DBCB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to accommodate Resident #62's need for a larger chair. The resident had gained weight and required a larger chair, and this had not been implemented as yet. This was evident for one (1) of fourteen (14) residents in the sample. Facility census: 81. Findings include: a) Resident #62 Observation of the resident, at breakfast in the third floor auditorium / dining area on 07/01/09, revealed he was seated in a ""go"" chair that appeared much too small for his size. His feet were back under the chair, and a lap tray was applied in such a manner that a portion of his stomach was resting on the tray. There was no room between him and the sides of the chair or between his body and the tray. He was noticed to move one foot and make circles with his chair most of the time, but he could advance the chair in one direction as well. (There were no injuries noted related to his feet and the positioning in the chair.) Direct care staff, when questioned regarding the size of his chair, stated they could not get another chair for him and the tray was out as far as it would go. Record review revealed physician's orders [REDACTED]. The quarterly minimum data set (MDS) assessment from June 2009 revealed the resident does have range of motion problems with his arm, leg, and foot, and he had gained nine (9) pounds since the quarterly review in January 2009. The surveyor questioned the administrator and physical therapy staff about this on the morning of 07/02/09. The physical therapist submitted an evaluation, completed on 06/24/09, indicating the resident was observed in a ""go"" chair. The first thing noticed was the resident had gained weight since January and the chair would soon be much too narrow for him. The seat was worn as well. Recommendations were made for a dietary consult for weight reduction, to reverse the padded arm supports to create additional space on the sides of the chair, and to reupholster the chair cushion. Nothing was mentioned regarding the position of the lap tray at this time. These interventions had not been completed at the time of the observation and review. an order for [REDACTED]. .",2015-01-01
10690,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2011-09-01,371,F,1,0,6LFO11,". Based on observations, facility policy review, and staff interview, the facility failed to assure foods were prepared, distributed, and served in a manner to reduce the potential of compromised food safety. Dietary personnel was consuming beverages in the food service preparation area (including around food preparation), handwashing was not in accordance with established procedures to reduce cross contamination, fresh vegetables were not washed prior to preparation, and food handler gloves were used after they were contaminated. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 93. Findings include: a) Observations of the kitchen, during the noon meal service on 08/31/11, found bottles of drinking water and other beverages in various locations around the kitchen. Each was located at a food preparation or in the food service area. Further observation found revealed a food service worker and a cook (Employees #15 and #29) drinking from these bottles during food preparation and food service. Another food service worker (Employee #27) brought an opened bottle of water into the kitchen and sat it on a counter beside of prepared foods. The assistant administrator / acting dietary manager (Employee #4) was present during these observations. The 2005 Food Code allows beverage consumption in the kitchen in areas away from food service and preparation, and only when beverages are in a cup with a lid and a straw; however, Employee #4 stated facility policy prohibited consumption of beverages in the kitchen under all circumstances. -- b) During the dietary observations beginning at 12:30 p.m. on 08/31/11, a cook (Employee #32) was observed preparing chopped lettuce. He did not wash the lettuce prior to preparation. Employee #32 stated he always chopped the lettuce, then washed it. This process allows for potential contamination on more surfaces, which, after chopping, are more susceptible to contamination; therefore, this action created a greater potential for contamination. Review of the facility's policy for food preparation, dated as reviewed 07/11/10, revealed all fresh vegetables were to be trimmed and washed prior to preparation. -- c) During the lettuce preparation observation noted above, Employee #32 wore food handler gloves. The gloves were not changed between touching soiled items and/or environmental objects. Employee #32 then wore these same contaminated gloves in the continuing preparation of the lettuce. -- d) Employee #32 was observed during handwashing at 12:35 p.m. on 08/31/11. When handwashing was completed, Employee #32 turned off the water faucet with a clean paper towel, then used that same paper towel to continue drying his hands and arms. This resulted in recontamination of Employee #32's hands with whatever was on the unsanitized water faucet. The assistant administrator / acting dietary manager (Employee #4) was present and confirmed the employee had not washed his hands in a manner which reduced the potential of cross contamination. .",2015-01-01
10691,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2011-09-01,441,F,1,0,6LFO11,". Based on observation and staff interview, the facility failed to assure practices were in place to prevent, to the extent possible, the onset and the spread of infection. Handwashing in the dietary department was not performed in accordance with established procedures to reduce cross contamination. This practice had the potential to affect all facility residents. Facility census: 93. Findings include: a) On 08/31/11 at 12:35 p.m., in the kitchen during tray preparation for the noon meal, a cook (Employee #32) was observed during handwashing. When handwashing was completed, Employee #32 turned off the water faucet with a clean paper towel, then used that same paper towel to continue drying his hands and arms. This resulted in recontamination of Employee #32's hands with whatever was on the unsanitized water faucet. The assistant administrator / acting dietary manager (Employee #4) was present and confirmed the employee had not washed his hands in a manner which reduced the potential of cross contamination.",2015-01-01
10509,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,312,E,0,1,UBFP11,". Based on observation, medical record review, and staff interview, the facility failed to assure five (5) of forty-five (45) Stage II sample residents were provided services to maintain good nutrition. These residents were unable to independently feed themselves but were not provided assistance from nursing staff to assure adequate intake. Resident identifiers: #101, #1, #71, #219, and #128. Facility census: 105. Findings include: a) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her uneaten meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance, and she was not provided assistance in eating her meal. She had eaten 50% or less of her breakfast. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the tray was removed from the resident's room. -- b) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her uneaten meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident had eaten 50% or less of her breakfast. The resident was not awakened to determine if she needed assistance, and she was not provided assistance in eating her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m., when the tray was removed from the resident's room. -- c) Resident #101 On 08/02/11 at 8:00 a.m., this resident was observed asleep with her uneaten breakfast in front of her. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not awakened or offered assistance in eating her meal prior to removal of her meal. She had eaten 25% or less of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. -- d) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not provided assistance to eat prior to removal of her meal. She had eaten 50% or less of her breakfast. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. -- e) Resident #219 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; he was just staring at his meal tray when observed at 8:00 and again at 8:16 a.m. At 8:25 a.m., he was observed sleeping with his uneaten meal in front of him. At 8:30 a.m., his room was entered by nursing staff and his tray was removed for disposal. He had eaten 50% or less of his meal. The resident was not provided assistance to complete his meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. .",2015-02-01
10510,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,224,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed to provide goods and services to one (1) of forty-five (45) Stage II sample residents to avoid physical harm and mental anguish. Resident #214 was experiencing pain in her left leg and did not receive treatment for [REDACTED]. She exhibited behaviors (e.g., combativeness), for which the facility obtained orders for and administered antianxiety and antipsychotic medications, but there was no evidence that pain was ruled out as a possible underlying cause the behaviors. The resident also sustained two (2) falls after the antianxiety medication and experienced lethargy after the antipsychotics were started. This resident also had an order to receive follow-up care for her [MEDICAL CONDITION] at the wound clinic. The facility did not make the appointment for this resident, and the wound was not evaluated by the wound clinic until after the surveyor intervened. The facility's failure to identify signs and symptoms of pain and to obtain follow-up care with the wound clinic as ordered resulted in the wound not being assessed and the resident experiencing untreated pain. Resident identifier: #214. Facility census: 105. Findings include: a) Resident #214 Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or if she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (vac) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. In Section 13.1a (integumentary / feet) of the admission nursing assessment, the assessor failed to mark a response to the following question: ""Is there pain associated with the wound/skin condition?"" - This section of the assessment was left blank. In Section 14.0 of the nursing admission assessment, the assessor responded as follows: - ""At anytime during the last five (5) days has the resident: Been on a scheduled pain medication regimen?"" = No - ""Been on a PRN (as needed) pain medication?"" = No - ""Had pain or hurting?"" = Yes (There was no follow-up documentation on the assessment to describe the pain or hurting the resident was experiencing.) - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound vac to measure and apply a new dressing. The wound vac dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). - Review of the resident's care plan, date 07/20/11, found the following (quoted as typed): - Problem - ""Pain / Potential for pain related to: [MEDICAL CONDITION]."" - Goals - ""Will report pain less than daily. Pain will decrease within 1 hour of intervention. Will be free from signs and symptoms of pain such as facial grimacing, moaning, or crying."" - Interventions - ""Monitor pain on scale of 1-10. Encourage resident to communicate presence of pain. Document/ report complaints & non-verbal signs of pain. Assist to reposition for comfort. Implement relaxation and/or distraction techniques to assist with pain control. Initialize Palliative Care referral. Encourage Resident to do mild exercise."" There was no recognition by staff that the resident was exhibiting signs and symptoms of pain with dressing changes. There was no plan to provide for routine pain medication and no plan to pre-medicate the resident for pain prior to completing dressing changes - such as when changing the dressing for the wound vac. - On 07/20/11 at 5:00 p.m., a nursing note recorded the resident did not display any combativeness or other behaviors. On 07/21/11, the nursing notes stated that she did not display any behaviors on that day either. According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (Review of the resident's Medication Administration Record [REDACTED].) On 07/24/11, nursing notes stated: ""S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. A nursing note, on 07/25/11, recorded receipt of new orders for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 25 mg BID (twice daily) for [MEDICAL CONDITION]. There was no documentation to reflect the resident was exhibiting signs or symptoms of [MEDICAL CONDITION], nor was there evidence to reflect staff had assessed the resident for pain. - Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. On 07/27/11, the resident's medical record was reviewed to review the factors surrounding this resident's falls. There was no evidence that this fall had been recorded in the nursing notes, no evidence to reflect staff conducted a physical assessment of the resident after the fall, and no evidence that staff had conducted an investigation in an effort to identify [MEDICATION NAME] and/or extrinsic factors that contributed to this fall. The incident / accident reports were reviewed for this time frame, and no report was found for the fall that occurred on 07/26/11. - On 07/28/11, a weekly nursing note stated: ""... she rips off wound vac, combative, curses staff, she is currently receiving [MEDICATION NAME] 25 mg BID. ..."" There was no evidence in the weekly interdisciplinary team (IDT) meeting note that pain was considered or ruled out as a reason for this resident's behaviors and pulling out her wound vac. - Review of the resident's physician orders [REDACTED]. - During observations of this resident on 08/03/11 from 10:00 a.m. to 11:30 a.m., she was noted to be sleeping the entire time. Her lunch tray was provided to her, and at 1:15 p.m., this surveyor approached the resident. She was very lethargic, dozing off while she was eating. When interviewed by the surveyor about her meal, she reported she just wasn't very hungry. (Even though the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE], the first doses of these medications were not available from the pharmacy for administration until the morning of 07/28/11.) Observation found the resident wrinkling her forehead and nose and grimacing. When asked if she was having pain, she stated ""yes"". When asked to describe her pain, she stated, ""A deep pain that is real deep and sharp shooting down my leg and into my foot."" When asked what treatment she received for pain, and she stated, ""It is all right. I do not need any more pills. I take too many now."" - At 1:30 p.m. on 08/03/11, two registered nurses (RNs - Employees #9 and #28A) were asked by this surveyor to assess this resident for pain. Employee #28A asked the resident if she was hurting anywhere, and the resident stated, ""Yes. My leg hurts from here to here."" (As she spoke, the resident pointed to the area surrounding the wound vac on her left lower leg.) The RN asked her if she wanted some pain medication, and she said, ""No. I don't think I need it."" - On 08/03/11, the nurse practitioner (Employee #29A) wrote a note to follow-up with the wound center as soon as possible if not already seen, and to obtain a report from the wound center if she has already been seen. Employee #29A also wrote an order for [REDACTED]."" - On 08/09/11 at 9:30 a.m., Employee #43 (a licensed practical nurse - LPN) was observed performing a treatment to Resident #214's leg. Throughout the procedure, the resident winced and gritted her teeth. At times, she covered her mouth with her sheet, and at other times, she covered her face with both hands, whimpering all the while. She repeated ""golly, golly"" time and time again. At one point, she asked the nurse to quit for a while and let her relax. It was apparent that this resident was in extreme pain, and this was confirmed by Employees #43 and #29A, who was also present at that time. Employee #29A said she would order something stronger for the resident. The treatment was stopped, and they said they were going to let the medication work before they finished the treatment. At 10:05 a.m., they administered [MEDICATION NAME] to the resident. - It was evident this resident was experiencing pain, and this untreated pain could have been the cause of her behaviors. There was no evidence that pain was considered as a causal or contributing factor prior to medicating the resident with antianxiety and antipsychotic medications for behaviors. There was inadequate monitoring of the resident's behaviors for the months of July and August 2011. No behavior monitoring sheet was found for July 2011. The behavior monitoring sheet for August 2011 indicated staff was to monitor her for the behavior of ""fighting"", and documentation on this sheet month-to date indicated she had no episodes of fighting. Additionally, no non-pharmacologic interventions were initiated in an attempt to reduce these behaviors prior to administering antianxiety and/or antipsychotic medications. During an interview with Employee #28A, she was made aware that there was no behavior sheet for July 2011 (when the antipsychotic and antianxiety medications were ordered and administered) and that no documentation was found to justify the use of either the antianxiety medication (e.g., evidence of increased anxiety) or the antipsychotic medications. There was also no evidence that the risks and benefits had been considered before using these medications. There was also no evidence that the facility had considered pain as a possible cause of the resident's combativeness (as she had exhibited combativeness when her wound care was done), nor was there any evidence that the facility considered the time of day that wound care had been done (at 4:00 a.m. - during hours of sleep) as a factor in the behaviors. The resident also suffered two (2) falls after these medications were initiated. The antianxiety and antipsychotic medications were administered without adequate indications for their use, without adequate monitoring, and in the presence of adverse effects (falls and lethargy), and the resident's pain (which was not identified as a possible underlying cause of her behaviors) was left untreated. Follow-up interviews with two (2) nurses (Employees #80 and on 08/08/11 at 12:00 p.m., revealed the facility failed to assure that the appointment was made for this resident to be seen by the wound clinic as ordered. Employee #53 stated during this interview that the nurse who took the order did not call on Monday to make the appointment. She stated the appointment was not made until brought to the attention of the facility by the nurse surveyor. .",2015-02-01
10511,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-10-27,368,E,0,1,UBFP12,". Based on observation and staff interview, the facility failed to assure residents without specific physician's orders for bedtime snacks were offered a snack at bedtime. This deficient practice affected more than an isolated number of residents currently residing in the facility. Facility census: 102. Findings include: a) Following receipt of a complaint by a family member concerning residents not receiving snacks at bedtime, the certified dietary manager (CDM - Employee #122) and regional registered dietitian (RD - Employee #131) were interviewed at 4:20 p.m. on 10/26/11. The CDM provided a list of foods prepared for bedtime snacks, which included twelve (12) half-sandwiches, twelve (12) cartons of milk, eight (8) single-serving containers of applesauce, six (6) single serving containers of pudding, twelve (12) packages of Graham crackers, two (2) containers of orange juice, six (6) packages of vanilla wafers, and six (6) single serving containers of vanilla ice cream. She stated the East wing of the facility was also sent this amount of food for bedtime snacks. The RD agreed that physician-ordered supplements (such as Mighty shakes) would not meet the intent of regulations for a bedtime snack. When asked what her understanding of what a bedtime snack consisted of, she stated ""milk or juice or beverage of choice and two (2) foods from the other food groups"". At 2:30 p.m. on 10/26/11, a registered nurse (RN) unit manager (Employee #80) was interviewed concerning bedtime snacks. She reported that a snack cart with prepared snacks was delivered from dietary, but the nursing staff did not routinely take this cart room to room and ask each resident if they would like something to eat. She stated that residents who did not get a physician-ordered snack could ask for one and the items would be available. She further stated that she knows some residents come up to the desk and ask for snacks. -- The facility was entered at 8:00 p.m. on 10/26/11 to conduct observations of the passing of bedtime snacks. The snack cart for the East unit of the facility arrived on the floor at approximately 8:35 p.m. A nursing assistant (Employee #24) stated she passed snacks on the East hallway. She stated, ""You have to offer a snack to everyone."" She stated that ""sometimes they run out"". She stated residents often wanted more sandwiches and less cracker-type snacks. She commented about residents getting hungry at night after snacks were passed and no one had access to the kitchen to get food. Employee #24 opened the door to the nutrition pantry and indicated there were two (2) containers of ice cream, two (2) containers of Jell-O pudding, a few packages of Cheez-it crackers and Graham crackers, as well as some packaged of snack crackers and a package of cocoa. A dietary employee (Employee #60) was observed to deliver a cart of snacks to the North and South wings of the facility at 8:40 p.m. She stated this was the first day in a long time that she had been instructed to prepare bedtime snacks. Observation of the cart found only twelve (12) half-sandwiches were present on the cart. When asked if she had prepared twelve (12) half-sandwiches for the East wing of the facility, she stated she had not had time to prepare that many sandwiches. .",2015-02-01
10512,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-10-27,224,D,1,0,2JCC11,". Based on observation, resident interview, and staff interview, the facility failed to provide goods and services to avoid physical harm and mental anguish for one (1) of thirteen (13) sampled residents. Resident #99 was left in his room clad in only an incontinence brief and a hospital gown (without a cover sheet or blanket) and with the air conditioning / heating unit next to this bed set to the fan mode. Resident #99 was also found to have dried bowel movement on his scrotum, buttock, and leg. Resident identifier: #99. Facility census: 102. Findings include: a) Resident #99 During random observations of the facility on 10/26/11 at 9:40 a.m., a male voice could be heard yelling, ""Nurse, nurse. Get me a blanket, nurse. I'm freezing, nurse."" A licensed practical nurse (LPN - Employee #28) was noted to be in the hallway with a medication cart. Observation of this male resident (#99), made from the doorway to his room, found him in his bed with only a hospital gown (which was pulled up to his chest) and a loosely applied incontinence brief. Resident #99 was rolling from side to side in his bed and opening his legs, and his pubic hair and scrotum were visible from the hallway. - After obtaining his permission, the resident's room was entered by this nurse surveyor. The resident immediately started yelling again to bring him a blanket, that he was freezing. Observation found there was no sheet or blanket on the resident's bed or on the floor next to the bed. Closer observation found the resident had a dried brown substance on the front of his leg, and the resident's fingernails were long, jagged, and packed with a brownish-colored substance. The resident stated that a ""nurse"" had come into his room, took his blanket, and turned the heat off. He repeatedly stated that he was freezing and asked this nurse surveyor to get him a blanket and turn his heat on. Observation of the air conditioning / heating unit by the resident's bed found it was set on fan mode and was blowing cool air. This nurse surveyor turned the heat on and informed the resident that staff would be notified of his request for a blanket. - Upon exiting the room, this nurse surveyor notified Employee #28 that Resident #99 did not have a sheet or blanket and was complaining of freezing. Employee #28 stated, as she entered his room, that the resident throws his covers in the floor. She looked around the resident's bed and did not find a sheet or blanket. She stated she would get him a blanket. - At 9:50 a.m. on 10/26/11, a nursing assistant (Employee #15) entered the resident's room with linens. The dried brown substance on the resident's leg was pointed out to Employee #15, who stated the resident had ""dried poop"" on him from last night and he wasn't like that when she left last night. She stated that she came in at 6:00 a.m. this morning (10/26/11) and Employee #63 (the nursing assistant who had cared for the resident on the previous shift) asked her to do a ""walk through"". Employee #15 reported that she had a resident who was going home that day and she wanted to give him a shower so he would be nice and clean, so she signed that she had done the ""walk through"" even though she did not actually do one with Employee #63. Employee #15 said she knew she shouldn't have done that, and that she realized this failure to perform the ""walk through"" with Employee #63 made the ""dried poop"" on Resident #99 her responsibility, even though he wasn't like that when she left last night. When asked if she had checked any of her residents for incontinence care needs this morning, she stated she had not. - Observations were conducted while Employee #15 provided incontinence care to Resident #15. The nursing assistant utilized three (3) washcloths to remove the copious amount of dried bowel movement from the resident's scrotum, left buttock, and left leg. - Employee #28 was informed that the resident was found with dried bowel movement on his body. The director of nursing (DON - Employee #12) was also notified of these findings at 10:15 a.m. on 10/26/11. .",2015-02-01
10513,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-10-27,312,E,1,0,2JCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, observation, medical record review, and staff interview, the facility failed to assure dependent residents received the necessary services to maintain good grooming and personal hygiene. Review of facility documentation of residents who were to receive showers on Tuesdays found that seventeen (17) of twenty-seven (27) residents had not received showers for up to twenty-four (24) days during the month of October 2011. Additionally, observation found the fingernails of one (1) of thirteen (13) sampled resident were long, jagged, and packed with brownish-colored debris. Resident identifiers: #23, #51, #91, #41, #9, #90, #11, #97, #26, #105, #30, #103, #64, #14, #100, #1, #61, and #99. Facility census: 102. Findings include: a) Showers 1. Resident #23 During the observation of the medication pass on 10/25/11 at 10:10 a.m., a family member of Resident #23 approached the medication cart and expressed to the licensed practical nurse (LPN - Employee #68) his concern that his mother had not had a shower. Review of Resident #23's medical record for the month of October 2011 found the Resident Functional Performance Record (RFPR), on which staff was to document on a daily basis how a resident received bathing - whether a bed bath or a shower - and how much staff assistance with bathing the resident required. According to documentation on Resident #23's RFPR, the resident had not received a shower since 10/10/11, a time period of fourteen (14) days. A follow-up interview with the concerned family member was conducted at 11:00 a.m. on 10/25/11. The family member stated he noticed that his mother had an odor and he had been trying since yesterday (10/24/11) to find out when she had last received a shower. - 2. Residents #51, #91, #41, #9, #90, #11, #97, #26, #105, #30, #103, #64, #14, #100, #1, and #61 A review of all residents scheduled to receive showers on Tuesdays was conducted with the director of nursing (DON - Employee #12) at 1:05 p.m. on 10/25/11. This audit of RFPRs found the following: The following residents had not received a shower in excess of twenty (20) days: - Resident #51 - Resident #91 - Resident #41 - Resident #9 - Resident #90 - Resident #11 - Resident #97 - Resident #26 - Resident #105 The following residents had not received showers in excess of ten (10) days: - Resident #30 - eighteen (18) days - Resident #103 - sixteen (16) days - Resident #64 - fifteen (15) days - Resident #14 - fourteen (14) days - Resident #100 - ten (10) days The following additional residents did not receive showers as scheduled: - Resident #1 - eight (8) days - Resident #61 was admitted on [DATE]. Documentation showed the resident had not received a shower since admission, a time period of seven (7) days. - Due to a discrepancy in documentation, a nursing assistant (Employee #10) was called to the DON's office. An in interview at 2:15 p.m. on 10/25/11, when asked why she had handwritten that residents had been given showers on a separate piece of paper, Employee #10 responded that she knew some of the staff was not giving residents' showers and she wanted to make sure that hers were documented. She further stated that the male residents would come up to her following a day off and complain that they did not receive showers unless she was there. - The DON was given an opportunity to provide evidence that the above residents actually received showers even though bed baths had been documented on the RFPR. She was unable to provide evidence that these residents had received showers when scheduled. -- b) Resident #99 During random observations of the facility on 10/26/11 at 9:40 a.m., a male voice could be heard yelling, ""Nurse, nurse. Get me a blanket, nurse. I'm freezing, nurse."" An LPN (Employee #28) was noted to be in the hallway with a medication cart. The resident's room was entered by this nurse surveyor. The resident immediately started yelling again to bring him a blanket, that he was freezing. Observation found there was no sheet or blanket on the resident's bed or on the floor. Further observation found the resident had a dried brown substance on the front of his leg, and the resident's fingernails were long, jagged, and packed with a brownish-colored substance. The resident stated that a ""nurse"" had come into his room and took his blanket and turned the heat off. .",2015-02-01
10514,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-10-27,157,D,1,0,YU5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the physician in a timely manner of a change in resident condition with potential to require medical intervention for one (1) of eight (8) sampled residents. Resident identifier: #58. Facility census: 96. Findings include: a) Resident #58 Review of nursing notes in Resident #58's medical record revealed an entry, at 8:00 p.m. on 10/20/11, by a licensed nurse (Employee #104) who ""observed a large raised area hard to touch c/o (complains of) being sore, not open, on left upper thigh next to his buttock"". Further review of nursing notes revealed, on 10/21/11 at 10:20 a.m., a licensed nurse (Employee #187) documented she had administered pain medication after Resident #58 stated the ""boil like area on my a** hurts"". The nurse wrote he refused therapy at 9:00 a.m. and was assisted to bed as he requested, then the nurse applied warm compresses to a ""hard raised area noted to back of L (symbol for left) leg under buttocks"". Review of the Medication Administration Record [REDACTED]. Review of nursing notes also revealed, at 5:00 p.m. on 10/21/11, Employee #104 applied warm compresses to a ""large area l (symbol for left) upper thigh near buttock"". Review of nursing notes, dated 10/23/11 at 5:30 p.m., found Resident #58 was ""very lethargic"", ""sweating and slow to respond"", and the family reported his ""speech is really slurred"". The physician on-call was notified, and orders were received to send him to the emergency room where he was later admitted . A nursing note, dated 10/23/11 at 10:00 p.m., stated he was admitted to the hospital with [REDACTED]. During an interview with a licensed nurse (Employee #108) on 10/27/11 at 11:40 a.m., she said she worked with Resident #58 on 10/22/11 and was not aware he had a boil. She looked at the treatment book and found no treatment orders for a boil and no orders for warm compresses. When asked, she said one would need to get an order for [REDACTED]. Interview with a nurse manager (Employee #142), on 10/27/11 at 11:45 p.m., revealed she was aware Resident #58 had a boil, but she did not work over the weekend of 10/22/11. She stated the nurse on duty on Sunday 10/23/11 saw a change in the resident and reported to the physician; although he had periods of intermittent confusion, he was not normally lethargic as he was the evening of 10/23/11. Review of the medical record found no evidence of physician notification of the hard raised area described as located on or under the left buttock. Interview with the director of nursing (DON), on 10/27/11 at 10:20 a.m., found she had the names of the nurses who worked the weekend of 10/22/11, but she had not spoken with them yet; an investigation was in process. Discussion also took place with the administrator on 10/27/11 at approximately noon, with no further information obtained. Interview with Resident #58's physician, on 10/27/11 at approximately 1:30 p.m., found he was not notified of the area on the left buttock; although he was out of town over the weekend 10/21/11 through 10/23/11, other physicians were on-call to cover the residents. He stated the lesion on the buttock was incised and drained in the hospital, was located only a few inches from the rectum, and may have begun as a perirectal abscess. He said the resident told him in the hospital this area had hurt for not more than a day or two (2) before being hospitalized . When asked, he agreed the resident had had intermittent periods of confusion since admission. .",2015-02-01
10515,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-10-27,309,D,1,0,YU5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to consistently monitor, treat, and/or reassess a change in physical status, which delayed medical intervention for one (1) of eight (8) sampled residents. Staff was aware of a resident's pain, administered oral pain medication for other than its intended use, and failed to notify the physician timely of a change in condition. Resident identifier: #58. Facility census: 96. Findings include: a) Resident #58 Review of Resident #58's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] for rehabilitation care including speech therapy, occupational therapy, and physical therapy following a recent cerebral artery occlusion with infarct (stroke). This resident had been determined to possess the capacity to understand and make informed health care decisions, but he had experienced intermittent periods of confusion since the stroke and had limited use of the affected upper and lower extremities. Other medical conditions include diabetes, [MEDICAL CONDITIONS], hypertension, anxiety, and depression. Review of nursing notes revealed the physician was notified by the nurse, on 10/06/11, that Resident #58 had back pain, a condition for which he took [MEDICATION NAME] 7.5/500 mg prior to admission to the facility. Subsequently, the physician ordered [MEDICATION NAME] 7.5/500 mg one (1) tablet every four (4) hours as needed (prn) for pain. Review of nursing notes in Resident #58's medical record revealed an entry, at 8:00 p.m. on 10/20/11, by a licensed nurse (Employee #104) who ""observed a large raised area hard to touch c/o (complains of) being sore, not open, on left upper thigh next to his buttock"". Further review of nursing notes revealed, on 10/21/11 at 10:20 a.m., a licensed nurse (Employee #187) documented she had administered pain medication after Resident #58 stated the ""boil like area on my a** hurts"". The nurse wrote he refused therapy at 9:00 a.m. and was assisted to bed as he requested, then the nurse applied warm compresses to a ""hard raised area noted to back of L (symbol for left) leg under buttocks"". Review of the Medication Administration Record [REDACTED]. Review of nursing notes also revealed, at 5:00 p.m. on 10/21/11, Employee #104 applied warm compresses to a ""large area l (symbol for left) upper thigh near buttock"". Review of nursing notes, dated 10/23/11 at 5:30 p.m., found Resident #58 was ""very lethargic"", ""sweating and slow to respond"", and the family reported his ""speech is really slurred"". The physician on-call was notified, and orders were received to send him to the emergency room where he was later admitted . A nursing note, dated 10/23/11 at 10:00 p.m., stated he was admitted to the hospital with [REDACTED]. During an interview with a licensed nurse (Employee #108) on 10/27/11 at 11:40 a.m., she said she worked with Resident #58 on 10/22/11 and was not aware he had a boil. She looked at the treatment book and found no treatment orders for a boil and no orders for warm compresses. When asked, she said one would need to get an order for [REDACTED]. Interview with a nurse manager (Employee #142), on 10/27/11 at 11:45 p.m., revealed she was aware Resident #58 had a boil, but she did not work over the weekend of 10/22/11. She stated the nurse on duty on Sunday 10/23/11 saw a change in the resident and reported to the physician; although he had periods of intermittent confusion, he was not normally lethargic as he was the evening of 10/23/11. Review of the medical record found no evidence of physician notification of the hard raised area described as located on or under the left buttock. During an interview with the director of nursing (DON), on 10/27/11 at 10:20 a.m., she said the licensed social worker (LSW - Employee #144) had completed a complaint form 10/24/11 from the spouse of Resident #58 related to concerns the spouse had about her husband's care the weekend of 10/22/11; she had obtained the names of nurses who worked the weekend of 10/22/11, but had not yet spoken with any of them. Discussion also took place with the administrator 10/27/11 at approximately noon, with no further information obtained. Review of the complaint form completed by Employee #144, dated 10/24/11, revealed complaints by Resident #58's spouse. In this complaint, the spouse made an allegation that she had told nurses her husband was ""not right"" since 10/20/11; he was ""talking out of his head"" on 10/22/11 and could not stay awake, according to his family. Also, the spouse allegedly said the boil on his hip was supposed to be treated with hot compresses, but this only been done one (1) day. Interview with Resident #58's physician, on 10/27/11 at approximately 1:30 p.m., found he was not notified of the area on the left buttock; although he was out of town over the weekend 10/21/11 through 10/23/11, other physicians were on-call to cover the residents. He stated the lesion on the buttock was incised and drained in the hospital, was located only a few inches from the rectum, and may have begun as a perirectal abscess. He said the resident told him in the hospital this area had hurt for not more than a day or two (2) before being hospitalized . When asked, he agreed the resident had had intermittent periods of confusion since admission. No further information was received from the DON or administrator prior to exit at 2:00 p.m. on 10/27/11.",2015-02-01
10516,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-10-31,280,D,1,0,4SLS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the plan of care after a change was made to the resident's treatment plan. Resident #157 had an indwelling urinary catheter inserted, and the resident's care plan was not revised to address the care needs of the resident related to the presence of this indwelling catheter. This was found for one (1) of six (6) sampled residents. Resident identifier: #157. Facility census: 156. Findings include: a) Resident #157 Review of this resident's care plan found a plan had been developed to address a problem with [MEDICAL CONDITION]. According to the care plan, she was readmitted to the facility from the hospital on [DATE] and she required frequent intermittent catheterization. Her care plan was last revised on 07/18/11 after her re-admission. Further review of the medical record revealed this resident had a chronic problem with [MEDICAL CONDITION], and intermittent catheterization had been required for some time, according to her history. The record contained a physician's orders [REDACTED]. May change FC (Foley catheter) and BSDB (bed side drainage bag) when occluded."" The resident's care plan was not revised to address the presence of this indwelling catheter and provide instructions to direct care staff for monitoring this catheter to prevent complications. Resident #157's care plan was reviewed with Employee #173 at 2:00 p.m. on 10/26/11. Employee #173 verified there was no revision evident for this care plan after the indwelling urinary catheter was inserted. .",2015-02-01
10517,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-10-31,309,G,1,0,4SLS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assess and monitor a resident with a history of [MEDICAL CONDITION] and an indwelling Foley urinary catheter, to prevent complications associated with this invasive intervention. Resident #157 had an indwelling urinary catheter inserted on 07/18/11 to treat [MEDICAL CONDITION]. Fluid output records completed by the nursing assistants noted there had been only 50 cc of urinary output from this indwelling catheter during the three-day period prior to her acute hospitalization on [DATE], with 0 cc recorded on 08/17/11 and 08/18/11, and only 50 cc recorded on 08/19/11. The fluid output records further reflected a urinary output of only 425 cc during the entire five-day period prior to her acute hospitalization on [DATE], while the nursing notes for this same time frame documented that the urinary catheter was ""patent"" (unobstructed) and draining yellow urine into the bedside drainage bag. There was no evidence the resident's decreased urinary output was communicated to a licensed nurse, nor was there evidence that a licensed nurse assessed the resident related to this decreased urinary output until 9:30 p.m. on 08/19/11. There was also no evidence the resident's daily fluid intake had been compared to her daily urinary output to identify a fluid imbalance, nor was there evidence to show staff notified the physician of the resident's poor urinary output over the five-day period preceding her acute hospitalization . The resident was transferred to the hospital emergency room (ER) on 08/19/11, where the ER physician noted on the early morning of 08/20/11 (quoted as typed): ""... this is the worst looking foley cath i have ever seen. with the tip of the catheter was almost completely occluded causing the patient [MEDICAL CONDITION] and causing pus to leak out around the foley filling the patients diaper. Pt (patient) smelt horrible. 1400 cc obtained after the Foley was changed. ..."" The lack of assessment / monitoring the use of the catheter, and failure to identify of the dysfunction of this urinary catheter, resulted in this resident being transferred to the ER and admitted to the hospital for further treatment due to [MEDICAL CONDITION]. This practice resulted in actual harm to one (1) of six (6) sampled residents and presented the potential for more than minimal harm was identified for three (3) of three (3) residents currently residing in the facility with indwelling urinary catheters that require monitoring. Resident identifiers: #157, #66, #84, and #20. Facility census: 156. Findings include: a) Resident #157 Review of Resident #157's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. She had previously been a patient multiple times in the hospital and in an acute rehabilitation facility, but after she experienced a decline in her condition, she was transferred to this facility. The resident had experienced a fluctuation in body temperature from the time she was admitted to this facility. The hospital had evaluated this and recorded that she had a fever of unknown origin. She had multiple tests and procedures to identify the cause of these temperature changes, but the reason for them was not identified. The medical record revealed that, in the past (prior to her admission to this facility), she had required intermittent catheterization due to [MEDICAL CONDITION] and she had chronic problems with urinary tract infections. She continued to require intermittent catheterization after her admission to the facility due to [MEDICAL CONDITION]. She had multiple medical [DIAGNOSES REDACTED]. This resident was nonverbal and required total care from the staff, including transfers with a mechanical lift. Upon her initial admission to this facility, she had an elevated temperature, and she was sent to the hospital on two (2) occasions since her admission on 06/24/11. She was exhibiting poor oral intake of food and fluids, and recommendations were made for a feeding tube. The facility had notified the family and they were waiting on the family to call them back with permission to proceed with having the feeding tube inserted as of 08/18/11, when she was transferred to the hospital. She was a full code, and it was expressed on her physician orders [REDACTED]. - The physician's monthly recapitulation orders for August 2011 contained the following orders: - 07/18/11 - ""Change bedside drainage bag when occluded or when foley catheter is changed. *schedule needed* - PRN."" - 07/18/11 - ""Change Foley Catheter when occluded, leaking, or as needed. *schedule needed* - PRN."" - 07/18/11- ""Foley catheter 16 FR with 5-10cc balloon to bedside straight drainage for [DIAGNOSES REDACTED]. - 07/18/11- ""Foley catheter care."" - A review of the nursing note entries related to the indwelling urinary catheter (quoted as typed): - 08/12/11 at 5:22 p.m. - ""... f/c (Foley catheter) patent and draining to bedside draingae bag ..."" - 08/13/11 at 2:14 a.m. - ""... foley patent draining yellow urine into bedside drainage bag."" - 08/13/11 at 1:47 p.m. - ""... foly cath that it patent and draining to bed side drainage bag ..."" - 08/14/11 at 3:20 a.m. - ""... foley cath patent draining yellow urine into BSDB (bedside drainage bag). ..."" - 08/15/11 at 3:51 p.m. - ""... has foley cath , patient and draining yellow urine into BSDS (bedside drainage system) ..."" - 08/16/11 at 10:48 a.m. - ""... foley cath patient and draining yellow urine to BSDB. ..."" - 08/17/11 - (There were no nursing notes written for this resident on 08/17/11.) - 08/18/11 at 1:56 p.m. - ""... foley patient and draining yellow urine to BSDB..."" - 08/19/11 at 3:56 a.m. - ""... foley cath patent draining yellow urine to BSDB..."" - 08/19/11 at 11:27 a.m. - ""P.C. (phone call) to (name) P.O.A. (power of attorney) of (Resident #157), unable to reach left her message on cell phone re: (regarding) possible [DEVICE], did not mention resident's name."" - 08/19/11 at 9:30 p.m. (Late Entry) - ""Notified of elevated temp 102.2 and pulse 140. Bowel sounds absent and abdomen hard and extended. Resident had no urine in BSDB and 3p-11p cna (certified nursing assistant) stated it wasn't emptied throughout her shift. Hydration protocol not completed by 7a-7p nurse and was left blank. Dr. (name) notified and t/o (telephone order) to send to (name of hospital) for evaluation. Notified POA of transfer."" - 08/19/11 at 9:58 p.m. - ""(Resident #157) transferred to hospital-unplanned for evaluation and treatment ... Res (resident) febrile w/ (with) elevated pulse rate. Abdomen hard t/t. x 4qds (quadrants) absent of Bowel sounds. ..."" There was no evidence recorded in any of the nursing notes leading up to the resident's acute transfer of any abnormal findings concerning the urinary catheter or the resident's urinary output. - The resident was transferred to the hospital emergency room (ER) on 08/19/11, where the ER physician recorded the following in the clinical report on the early morning of 08/20/11 (quoted as typed): ""... this is the worst looking foley cath i have ever seen. with the tip of the catheter was almost completely occluded causing the patient [MEDICAL CONDITION] and causing pus to leak out around the foley filling the patients diaper. Pt (patient) smelt horrible. 1400 cc obtained after the Foley was changed. ..."" - A review of fluid intake and output records for Resident #157 found the following information about her urinary output (recorded per shift) on the days leading up to her acute hospitalization : On 08/19/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 50 cc - 3 to 11 shift - 0 cc 24-hour total = 50 cc On 08/18/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 0 cc - 3 to 11 shift - blank (nothing recorded) 24-hour total = 0 cc On 08/17/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 0 cc - 3 to 11 shift - 0 cc 24-hour total = 0 cc On 08/16/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 50 cc - 3 to 11 shift - 25 cc 24-hour total = 75 cc On 08/15/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 200 cc - 3 to 11 shift - 0 cc 24-hour total = 200 cc On 08/14/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 300 cc - 3 to 11 shift - 200 cc 24-hour total = 500 cc On 08/13/11 - 11 to 7 shift - 200 cc - 7 to 3 shift - 175 cc - 3 to 11 shift - 100 cc 24-hour total = 475 cc - A review of the resident's care plan, dated 07/04/11, revealed there was no plan addressing the care of her indwelling urinary catheter. The resident had a plan that identified her risk for [MEDICAL CONDITION] which required intermittent catheterization. This plan, dated 07/18/11, directed staff to assess the resident for bladder distention and to monitor her urinary output for color, consistency, and amount. There was no evidence this was done or that interventions were added when an indwelling catheter was inserted, to prevent complications of its use. - During an interview on 10/25/11 at 10:00 a.m., the director of nursing (DON - Employee #127) verified the facility had identified some issues related to communication of the residents' urinary output and the monitoring of the catheters. She also verified staff inservicing had been conducted, a new form had been implemented for measuring urinary output, and nurses had been suspended for not assessing this resident's urinary output. The DON stated the nurses were to review and initial this new output form each shift to verify they reviewed it. (Review of the form found a box for recording the nurse's initials.) She also verified that, at this facility, nurses worked 12-hour shifts and nursing assistants worked 8-hour shifts, so there should be initials from three (3) nursing assistants and two (2) nurses on this form daily. - A review of the new catheter care and output documentation, which was implemented as a result of the nurses failing to assess the urinary outputs of residents with catheters, found these new forms were not being completed and checked by the nurses as instructed. Failure to monitor a resident's output urinary daily could result in any dysfunction of the catheter going undetected. The records of three (3) residents with indwelling urinary catheters present were reviewed for these new output records: 1. Resident #20 This resident was identified as having an indwelling urinary catheter. Record review revealed he had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the twenty (20) days reviewed, three (3) shifts had no urinary output recorded. Seventeen (17) days had no evidence that two (2) nurses reviewed this resident's urinary output. Five (5) days had no evidence that this resident's urinary output was reviewed by even one (1) nurse. This review found this new output form was not being completed as intended, to reflect daily monitoring of the resident's urinary output and assure the indwelling catheter was functioning properly. - 2. Resident #84 This resident was identified as having an indwelling urinary catheter. Record review revealed she had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the twenty-five (25) days reviewed, three (3) shifts had no urinary output recorded. Twenty-one (21) days had no evidence that two (2) nurses reviewed this resident's urinary output. Nine (9) days had no evidence that this resident's urinary output was reviewed by even one (1) nurse. This review found this new output form was not being completed as intended, to reflect daily monitoring of the resident's urinary output and assure the indwelling catheter was functioning properly. - 3. Resident #66 This resident was identified as having an indwelling urinary catheter. Record review revealed he had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the five (5) days reviewed, one (1) shift had no urinary output recorded and was not initialed by a nursing assistant. There was also no evidence that a nurse reviewed the resident's urinary output for this shift or further assessed the reason for the blanks. - During an interview on 10/26/11 at 2:30 p.m., the unit manager (Employee #95) verified she was aware that the forms were no always being completed. She verified there were blanks on the forms where the aides failed to record the urinary output each shift and blanks where the nurses failed to initial the boxes to verify they had reviewed each resident's urinary output on each shift. .",2015-02-01
10518,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-10-31,386,D,1,0,4SLS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the attending physician signed and dated orders with each visit. Resident #157's medical record contained multiple physician telephone orders that had not been reviewed and signed by the physician. There were orders in the medical record from 07/20/11 that were not reviewed and signed as of 10/24/11. This was found to be true in one (1) of one (6) records reviewed. Resident identifier: #157. Facility census: 156. Findings include: a) Resident #157 Review of Resident #157's closed medical record, on 10/24/11, found several pages flagged for the physician to sign. Further review of this record found the resident was admitted [DATE] and discharged from the facility on 08/30/11. There were multiple physician telephone orders receive in July and August 2011 not were signed by the physician, as well as orders for therapy that were written on 07/20/11 and signed and dated by the physician as required. This was a period of three (3) months since these orders had been written. The director of nursing (DON - Employee #127), when interviewed on 10/24/11, verified these orders had not been signed and dated and agreed that this should have been completed by now. She also verified physician followed other residents in the facility and had been in the facility on multiple occasions since Resident #157's discharged on [DATE]. .",2015-02-01
10519,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-10-31,514,D,1,0,4SLS11,". Based on record review and staff interview, the facility failed to maintain complete and accurate clinical records for one (1) of six (6) sampled residents. Resident identifier: #157. Facility census: 156. Findings include: a) Resident #157 1. Review of Resident #157's closed medical record found documents in her record that were not dated or labeled with the resident's name, to verify that all documents in her record actually belonged to her. Examples were as follows: - An intake record dated July 15th - 28th, 2011 with no resident name written on either side of the document. - An intake and output record dated July 29th - 31st with no resident name written on either side of the document. - A meal intake record for month of August 2011 with no resident name written on either side of the document. - A weekly bath and skin report dated August 2011 with no resident name written on either side of the document. -- 2. Further record review revealed an intake and output record in Resident #157's closed record that was labeled with another resident's name. This document was shown to the director of nursing (DON - Employee #127) on 10/25/11 at 10:00 a.m., and she was made aware that this output record was not Resident #157's. -- 3. The DON verified there were numerous documents in Resident #157's closed record without names and dates.",2015-02-01
10520,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-08-04,225,D,1,0,MLNK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of self-reported allegations of abuse / neglect and injuries of unknown origin, medical record review, staff interview, and policy review completed during a complaint investigation conducted at this facility from 08/01/11 through 08/04/11, the facility failed to comply with all elements of this requirement as follows: The facility failed to immediately report (within no more than twenty-four (24) hours) all allegations of abuse / neglect to all applicable State officials as required by law. In cases where the alleged perpetrators were nurse aides, the facility also failed to consistently report allegations of abuse / neglect to the Nurse Aide Registry. The facility failed to thoroughly investigate all allegations of abuse / neglect. The facility failed to report the results of all investigations to State officials in accordance with State law (including the State survey and certification agency) within five (5) working days of the incident. For follow-up reports made to adult protective services (APS), such written reports are to be completed and submitted to APS within forty-eight (48) hours in accordance with WV State Code. The facility also failed to protect residents during the course of the facility's internal investigations into allegations of abuse / neglect, by allowing alleged perpetrators to continue providing direct care to residents until the facility substantiated the allegations and terminated their employment. These deficient practices were true for four (4) of twelve (12) self-reported allegations reviewed. Resident identifiers: #4, #3, #95, and #64. Facility census: 143. Findings include: a) Resident #4 Review of an immediate fax reporting form sent to the State survey agency's Nursing Home Program revealed the following allegation had been made by Resident #4 against a male nursing assistant (Employee #2): ""CNA (certified nursing assistant) mean to resident."" The date of the alleged incident was 07/25/11. The immediate reporting form was signed by the director of nursing (DON) - as the person completing the form - and dated 07/30/11. The initial report of this allegation was not made to the correct agency (the State's Nurse Aide Registry), even though the alleged perpetrator was a nursing assistant. Additionally, this initial report was not made to the State survey agency (or the Nurse Aide Registry) within twenty-four (24) hours of receipt of the allegation by facility staff. - Review of the APS reporting form related to this alleged event that occurred on 07/25/11 found the form was completed by the DON on 07/30/11. (This form is for follow-up reporting, as all immediate reporting to APS is to be accomplished through telephone contact with the local APS office or the APS hotline after hours.) Instructions at the bottom of this form stated: ""A copy of this report must be filed with the following parties by the person completing the form (within 48 hours)."" This follow-up reporting to APS did not occur within the required time frame. - Review of the five-day follow-up reporting form sent to the Nursing Home Program found the following narrative: ""CNA & resident both stated resident was starting to fall & resident ended up falling face first on to bed."" This form was also signed by the DON - as the person completing the form - and dated 07/30/11. The facility did not substantiate any abuse by Employee #2 against Resident #4. - Review of Resident #4's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]; her list of active [DIAGNOSES REDACTED]. - Review of the facility's internal investigation into the above-referenced allegation by Resident #4 revealed the following statements: - A typed witness statement collected from a registered nurse (RN - Employee #4) with a dated signature of 07/25/11, which contained the following (quoted as typed): ""resident in room sitting in wheelchair with signs of distress, crying, resident stated that the man who had been taking care of her had hurt her feelings. Asked nurse supervisor to come to room as a witness, resident unable to verbalize the actions that had been taken against her. ""After resident had calmed down she was able to be interviewed. resident states CNA (certified nursing assistant) was bringing her back from the shower and that she was telling him she was not ready to go back to bed yet. resident stated that he was putting her back to bed anyway and stood her up. resident states she was dropped on the bed on her weak side and was left lying there helpless. resident states her aid stated 'you cant do anything about it'. resident feels that her aid was picking on her. she states she was not harmed physically, but was harmed mentally and emotionally. Upon assessment no signs of physical injury was noted. resident stated she got back in wheelchair herself. resident calmed and reassured that incident would be investigated."" Handwritten at the beginning of the narrative were ""7/25/11"", ""2000 (8:00 p.m.)"", and a room number. - A typed statement collected from another RN (Employee #48) with a dated signature of 07/25/11, which contained the following (quoted as typed): ""Was asked to accompany nurse to resident (room number)'s room due to resident being upset. Upon entering the room resident was visibly upset and crying. When questioned on why she was upset resident could not verbalize clearly what was bothering her but she did say that 'he was mean to me'. When asked to elaborate on who 'he' was resident verbalized 'You know, the boy in blue' (this nurse did note resident's CNA is in all blue this shift). When questioned about what she meant by mean the resident could not verbalize. When resident was asked if 'he' was physically or mentally mean the resident stated mentally. Resident could not verbalize what 'he' said that was 'mean' but did state she no longer wished to receive care from 'him'."" - A statement handwritten by Employee #4, with a dated signature of 07/25/11, which contained the following (quoted as written): ""Assessment done on resident. Pupils equal et (and) reactive. resident awake, alert, understanding verbal cues. Bilateral pulses present. No apparent injuries noted. No skin tears noted. Vital signs ... . No skin discoloration noted. ""Resident able to talk to sister. MPOA (medical power of attorney representative) updated. DON updated. Resident able to express herself after she had calmed down. Resident states that her aid focused on her disability and made her feel hurt and weak. ..."" - A handwritten statement by Employee #2 (the alleged perpetrator), with a dated signature of 07/25/11, which contained the following (quoted as written): ""(Illegible) i took her to her room after shower and I went to put her to Bed and she stand up and lost (illegible) and i took her to the Bed and (illegible) her up."" - A typed summary of an interview by the DON of Employee #2, dated / signed by the DON on 07/26/11, which contained the following (quoted as typed): ""Spoke with (Employee #2) on 7/25/2011 to ask him what had occurred with (Resident #4) the previous evening. (Employee #2) stated ""1. He had given resident a shower ""2. After transferring resident from shower chair to wheelchair he wheeled the resident to her room ""3. When he went to place resident in bed, she started to fall and fell face first onto the bed ""4 He stated he straightened her up in bed ""5. He applied a brief on the resident ""6. He stated he then covered her up and then left the room"" - A typed summary of the overall investigation, dated / signed by the DON on 07/30/11, which contained the following (quoted as typed): ""... 6. Investigation was that the resident and CAN essentially told the same story. Resident denied CAN had hurt her. ""6. I told with the son, (name), after the investigation and informed him the stories were essentially the same but I felt his mother may have gotten scared when she fell . We discussed that the resident stated she was lying face down form approximately 1 minute and it wold be frightening to her if she could not get herself out of that position. ""7. I could see no wrong doing on the part of the CNA and he was taken off suspension and allowed to return to work on July30th."" - There was no evidence in the statements collected by the facility or in the narrative summary compiled by the DON that staff investigated the resident's allegation that she informed Employee #2 she was not ready to go to bed after her shower, that he told her he was putting her to bed anyway, and that he then put her to bed against her wishes. (According to the typed statement by Employee #4, this exchanged preceded the fall that occurred when Employee #2 transferred Resident #4 from her wheelchair to her bed.) - The DON was interviewed at 2:00 p.m. on 08/02/11. She stated, ""They were late."" She further verified the immediate and five-day reports were not faxed to State officials until 08/01/11. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)."" - Review of Section 9-6-11 of the West Virginia State Code found: ""A report of neglect or abuse of an incapacitated adult or facility resident or of an emergency situation involving an adult shall be made immediately by telephone to the department's local adult protective services agency and shall be followed by a written report by the complainant or the receiving agency within forty-eight hours. ..."" - According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities (Revision, August 2009), ""Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is a nurse aide whose identity if known, are to be immediately reported to OHFLAC's Nurse Aide Program and not to OHFLAC's Nursing Home Program."" The facility was unable to provide evidence the CNA was reported to the State Nurse Aide Registry (also known as the Nurse Aide Program) as required. Instead, the allegation involving this CNA was reported to the Nursing Home Program, which does not investigate nurse aides who are on the State's Nurse Aide Registry. - The DON confirmed the allegation of abuse by Resident #4 was not reported to State officials until 08/01/11, seven (7) days after the allegation was reported to staff by Resident #4 on 07/25/11. -- b) Resident #33 Review of an immediate fax reporting form sent to the Nursing Home Program revealed an incident involving Resident #33. According to the documentation on the reporting form (quoted as written): ""pt (patient) woke up c/o (complaining of) thumb pain. Xray obtained. Denies injury - does not know how thumb got hurt."" This form was completed by the DON on 07/26/11. Review of the facility's internal investigation into this injury of unknown source revealed a statement was taken from the resident on 07/22/11 and an x-ray was taken of the resident's thumb on 07/22/11. The initial reporting of this injury of unknown source did not occur within twenty-four (24) hours of receipt by facility staff of the complaint. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)."" - The DON, when interviewed on 08/02/11 at 2:00 p.m., was unable to provide evidence the incident was immediately reported to the State officials on 07/22/11, when the facility became aware of the incident. The DON verified the incident was not reported to State officials until 08/01/11. -- c) Resident #95 Review of an immediate fax reporting form sent to the Nursing Home Program revealed Resident #95 alleged that a nursing assistant (Employee #174) ""unplugged"" her call light on 07/24/11. The immediate reporting form was signed by the DON - as the person completing the form - and dated 07/30/11. The initial report of this allegation was not made to the correct agency (the State's Nurse Aide Registry), even though the alleged perpetrator was a nursing assistant. Additionally, this initial report was not made to the State survey agency (or the Nurse Aide Registry) within twenty-four (24) hours of receipt of the allegation by facility staff. - Review of the facility's internal investigation into this allegation revealed a handwritten statement from a licensed practical nurse (LPN - Employee #78) dated 07/24/11 which contained the following (quoted as written): ""This nurse heard resident calling my name. This nurse entered room, resident wanted glasses cleaned and stated CNA had unplugged call light. Call light was out of wall. This nurse cleaned glasses and replaced call light. approached CNA and questioned if this had happened and she replied 'yes.' This was reported to RN supervisor. This nurse apologized to resident."" - Review of the five-day follow up report, dated as having been completed by the DON on 07/30/11, revealed the corrective action taken by the facility was suspension and termination of the CNA. - Review of the CNA's time card revealed she worked a complete shift on 07/24/11, arriving at 2:55 p.m. and leaving at 10:58 p.m. This employee also worked a double shift from 2:54 p.m. on 07/28/11 until 7:00 a.m. on 07/29/11. - Review of the ""Current Employee List As of 8/1/11"", which was supplied to the survey team at the start of this on-site complaint investigation on 08/01/11, revealed Employee #174 was identified as a current employee. - The DON, when interviewed at 2:00 p.m. on 08/02/11, was unable to provide evidence the CNA was suspended when the facility became aware of the incident. She also verified the CNA continued to work at the facility until 07/28/11. The DON further verified the incident was not immediately reported to State officials on 07/24/11. The DON stated she faxed the information to State officials on 08/01/11. - The administrator, when interviewed at approximately 10:00 a.m. on 08/04/11, stated, ""There was a communication problem between the HR (human resources) and the scheduler. It happened, that is all I can say. It should not have happened."" - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress."" -- d) Resident #64 Review of an immediate fax reporting form sent to the Nursing Home Program revealed incidents involving Resident #64, which were noted by the person completing the form (the DON) as having occurred on 05/25/11. The description of the incident was as follows (quoted as written): ""Resident report to one nurse that he was beaten-up in the shower room and to another nurse he relayed he was smacked in the face & punched in the ribs while in his room. Report made to nursing staff evening of 5/26/11."" Where the form prompted the author to identify the name of the alleged perpetrator, the person completing the form (the DON) noted ""Unknown"". The DON dated her signature to indicate she completed this immediate reporting form on 05/27/11. This immediate reporting was not completed within twenty-four (24) hours of the facility's receipt of the complaint by Resident #64. - Review of the facility's internal investigation into this incident revealed the following statements had been collected: - A typed statement from an LPN (Employee #177), signed by Employee #177 on 05/26/11, which stated (quoted as typed): ""Upon assessment and administration of meds resident told this nurse that Wed night the 18th day of May 2011 That the two aids that were giving (Resident #64) his shower were pulling and tugging on him so hard that he heard his ribs crack and he thought they were broke. Resident also stated that 'Dave told him that he was going to kill me."""" - A typed statement from an RN (Employee #35), signed by Employee #35 on 05/26/11, which stated (quoted as typed): ""RESIDENT STATES, 'DANNY AND JIMMY WAS YANKING AND PULLING ON ME LAST WEDNESDAY CRACKING MY RIBS'. ..."" - The facility's internal investigation contained no other statements, including no statements from any nursing assistants assigned to care for the resident on 05/18/11 and no statement from the resident's roommate. - Review of the five-day follow-up report for Resident #64 revealed the following (quoted as written): ""Resident initial stated he was beaten-up in the shower, then stated he was pulled & tugged on in the shower, then stated he was slapped & hit when in bed. first talked about 'Dave' then 'Danny & Jimmy' (1) No marks on pt (patient) (2) Rib x-ray negative (3) No employees caring for resident by the names of 'Dave, Danny, or Jimmy.' Claim unsubstantiated."" The form was signed by the person completing the report (the DON) on 05/31/11. - During an interview with the DON on the afternoon of 08/02/11, she stated the facility did not have any employees with the same first name as identified by Resident #64 (""Dave"", ""Danny"", or ""Jimmy""); therefore, no statements were taken from any other employees. - Review of the nursing schedule revealed two (2) nursing assistants (Employees #176 and #82) whose first names matched two (2) of the three (3) nicknames identified by Resident #64. Both nursing assistants were employed at the facility during the time the alleged abuse was reported by the resident, and Employee #176 worked a double shift on Resident #64's floor on the date of the alleged abuse (05/18/11). - When interviewed on 08/03/11 at 1:33 p.m., a nursing assistant (Employee #120) stated Resident #64 frequently made complaints about people beating him up and not receiving care. She further added that Resident #64 had not complained about people beating him up since he accused Employee #176 of beating him up. When interviewed on 08/03/11 at 1:55 p.m., a licensed practical nurse (LPN - Employee #62) stated Resident #64 was always complaining about his care. The LPN reported Resident #64 would always say that Employee #176 was hitting him. She stated that, if the facility reported everything the resident said, they would be reporting every day. - There was no evidence to reflect the facility conducted a thorough investigation into this resident's allegation of physical abuse by two (2) employees whom the resident identified by first name and who were employed at the time of the alleged incident. .",2015-02-01
10521,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-08-04,226,D,1,0,MLNK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of self-reported allegations of abuse / neglect and injuries of unknown origin, medical record review, staff interview, and policy review completed during a complaint investigation conducted at this facility from 08/01/11 through 08/04/11, the facility failed to implement their policy and procedures for reporting and investigating allegations of abuse / neglect and injuries of unknown origin as follows: The facility failed to immediately report (within no more than twenty-four (24) hours) all allegations of abuse / neglect to all applicable State officials as required by law. In cases where the alleged perpetrators were nurse aides, the facility also failed to consistently report allegations of abuse / neglect to the Nurse Aide Registry. The facility failed to thoroughly investigate all allegations of abuse / neglect. The facility failed to report the results of all investigations to State officials in accordance with State law (including the State survey and certification agency) within five (5) working days of the incident. For follow-up reports made to adult protective services (APS), such written reports are to be completed and submitted to APS within forty-eight (48) hours in accordance with WV State Code. The facility also failed to protect residents during the course of the facility's internal investigations into allegations of abuse / neglect, by allowing alleged perpetrators to continue providing direct care to residents until the facility substantiated the allegations and terminated their employment. These deficient practices were true for four (4) of twelve (12) self-reported allegations reviewed. Resident identifiers: #4, #3, #95, and #64. Facility census: 143. Findings include: a) Resident #4 Review of an immediate fax reporting form sent to the State survey agency's Nursing Home Program revealed the following allegation had been made by Resident #4 against a male nursing assistant (Employee #2): ""CNA (certified nursing assistant) mean to resident."" The date of the alleged incident was 07/25/11. The immediate reporting form was signed by the director of nursing (DON) - as the person completing the form - and dated 07/30/11. The initial report of this allegation was not made to the correct agency (the State's Nurse Aide Registry), even though the alleged perpetrator was a nursing assistant. Additionally, this initial report was not made to the State survey agency (or the Nurse Aide Registry) within twenty-four (24) hours of receipt of the allegation by facility staff. - Review of the APS reporting form related to this alleged event that occurred on 07/25/11 found the form was completed by the DON on 07/30/11. (This form is for follow-up reporting, as all immediate reporting to APS is to be accomplished through telephone contact with the local APS office or the APS hotline after hours.) Instructions at the bottom of this form stated: ""A copy of this report must be filed with the following parties by the person completing the form (within 48 hours)."" This follow-up reporting to APS did not occur within the required time frame. - Review of the five-day follow-up reporting form sent to the Nursing Home Program found the following narrative: ""CNA & resident both stated resident was starting to fall & resident ended up falling face first on to bed."" This form was also signed by the DON - as the person completing the form - and dated 07/30/11. The facility did not substantiate any abuse by Employee #2 against Resident #4. - Review of Resident #4's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]; her list of active [DIAGNOSES REDACTED]. - Review of the facility's internal investigation into the above-referenced allegation by Resident #4 revealed the following statements: - A typed witness statement collected from a registered nurse (RN - Employee #4) with a dated signature of 07/25/11, which contained the following (quoted as typed): ""resident in room sitting in wheelchair with signs of distress, crying, resident stated that the man who had been taking care of her had hurt her feelings. Asked nurse supervisor to come to room as a witness, resident unable to verbalize the actions that had been taken against her. ""After resident had calmed down she was able to be interviewed. resident states CNA (certified nursing assistant) was bringing her back from the shower and that she was telling him she was not ready to go back to bed yet. resident stated that he was putting her back to bed anyway and stood her up. resident states she was dropped on the bed on her weak side and was left lying there helpless. resident states her aid stated 'you cant do anything about it'. resident feels that her aid was picking on her. she states she was not harmed physically, but was harmed mentally and emotionally. Upon assessment no signs of physical injury was noted. resident stated she got back in wheelchair herself. resident calmed and reassured that incident would be investigated."" Handwritten at the beginning of the narrative were ""7/25/11"", ""2000 (8:00 p.m.)"", and a room number. - A typed statement collected from another RN (Employee #48) with a dated signature of 07/25/11, which contained the following (quoted as typed): ""Was asked to accompany nurse to resident (room number)'s room due to resident being upset. Upon entering the room resident was visibly upset and crying. When questioned on why she was upset resident could not verbalize clearly what was bothering her but she did say that 'he was mean to me'. When asked to elaborate on who 'he' was resident verbalized 'You know, the boy in blue' (this nurse did note resident's CNA is in all blue this shift). When questioned about what she meant by mean the resident could not verbalize. When resident was asked if 'he' was physically or mentally mean the resident stated mentally. Resident could not verbalize what 'he' said that was 'mean' but did state she no longer wished to receive care from 'him'."" - A statement handwritten by Employee #4, with a dated signature of 07/25/11, which contained the following (quoted as written): ""Assessment done on resident. Pupils equal et (and) reactive. resident awake, alert, understanding verbal cues. Bilateral pulses present. No apparent injuries noted. No skin tears noted. Vital signs ... . No skin discoloration noted. ""Resident able to talk to sister. MPOA (medical power of attorney representative) updated. DON updated. Resident able to express herself after she had calmed down. Resident states that her aid focused on her disability and made her feel hurt and weak. ..."" - A handwritten statement by Employee #2 (the alleged perpetrator), with a dated signature of 07/25/11, which contained the following (quoted as written): ""(Illegible) i took her to her room after shower and I went to put her to Bed and she stand up and lost (illegible) and i took her to the Bed and (illegible) her up."" - A typed summary of an interview by the DON of Employee #2, dated / signed by the DON on 07/26/11, which contained the following (quoted as typed): ""Spoke with (Employee #2) on 7/25/2011 to ask him what had occurred with (Resident #4) the previous evening. (Employee #2) stated ""1. He had given resident a shower ""2. After transferring resident from shower chair to wheelchair he wheeled the resident to her room ""3. When he went to place resident in bed, she started to fall and fell face first onto the bed ""4 He stated he straightened her up in bed ""5. He applied a brief on the resident ""6. He stated he then covered her up and then left the room"" - A typed summary of the overall investigation, dated / signed by the DON on 07/30/11, which contained the following (quoted as typed): ""... 6. Investigation was that the resident and CAN essentially told the same story. Resident denied CAN had hurt her. ""6. I told with the son, (name), after the investigation and informed him the stories were essentially the same but I felt his mother may have gotten scared when she fell . We discussed that the resident stated she was lying face down form approximately 1 minute and it wold be frightening to her if she could not get herself out of that position. ""7. I could see no wrong doing on the part of the CNA and he was taken off suspension and allowed to return to work on July30th."" - There was no evidence in the statements collected by the facility or in the narrative summary compiled by the DON that staff investigated the resident's allegation that she informed Employee #2 she was not ready to go to bed after her shower, that he told her he was putting her to bed anyway, and that he then put her to bed against her wishes. (According to the typed statement by Employee #4, this exchanged preceded the fall that occurred when Employee #2 transferred Resident #4 from her wheelchair to her bed.) - The DON was interviewed at 2:00 p.m. on 08/02/11. She stated, ""They were late."" She further verified the immediate and five-day reports were not faxed to State officials until 08/01/11. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)."" - Review of Section 9-6-11 of the West Virginia State Code found: ""A report of neglect or abuse of an incapacitated adult or facility resident or of an emergency situation involving an adult shall be made immediately by telephone to the department's local adult protective services agency and shall be followed by a written report by the complainant or the receiving agency within forty-eight hours. ..."" - According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities (Revision, August 2009), ""Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is a nurse aide whose identity if known, are to be immediately reported to OHFLAC's Nurse Aide Program and not to OHFLAC's Nursing Home Program."" The facility was unable to provide evidence the CNA was reported to the State Nurse Aide Registry (also known as the Nurse Aide Program) as required. Instead, the allegation involving this CNA was reported to the Nursing Home Program, which does not investigate nurse aides who are on the State's Nurse Aide Registry. - The DON confirmed the allegation of abuse by Resident #4 was not reported to State officials until 08/01/11, seven (7) days after the allegation was reported to staff by Resident #4 on 07/25/11. -- b) Resident #33 Review of an immediate fax reporting form sent to the Nursing Home Program revealed an incident involving Resident #33. According to the documentation on the reporting form (quoted as written): ""pt (patient) woke up c/o (complaining of) thumb pain. Xray obtained. Denies injury - does not know how thumb got hurt."" This form was completed by the DON on 07/26/11. Review of the facility's internal investigation into this injury of unknown source revealed a statement was taken from the resident on 07/22/11 and an x-ray was taken of the resident's thumb on 07/22/11. The initial reporting of this injury of unknown source did not occur within twenty-four (24) hours of receipt by facility staff of the complaint. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)."" - The DON, when interviewed on 08/02/11 at 2:00 p.m., was unable to provide evidence the incident was immediately reported to the State officials on 07/22/11, when the facility became aware of the incident. The DON verified the incident was not reported to State officials until 08/01/11. -- c) Resident #95 Review of an immediate fax reporting form sent to the Nursing Home Program revealed Resident #95 alleged that a nursing assistant (Employee #174) ""unplugged"" her call light on 07/24/11. The immediate reporting form was signed by the DON - as the person completing the form - and dated 07/30/11. The initial report of this allegation was not made to the correct agency (the State's Nurse Aide Registry), even though the alleged perpetrator was a nursing assistant. Additionally, this initial report was not made to the State survey agency (or the Nurse Aide Registry) within twenty-four (24) hours of receipt of the allegation by facility staff. - Review of the facility's internal investigation into this allegation revealed a handwritten statement from a licensed practical nurse (LPN - Employee #78) dated 07/24/11 which contained the following (quoted as written): ""This nurse heard resident calling my name. This nurse entered room, resident wanted glasses cleaned and stated CNA had unplugged call light. Call light was out of wall. This nurse cleaned glasses and replaced call light. approached CNA and questioned if this had happened and she replied 'yes.' This was reported to RN supervisor. This nurse apologized to resident."" - Review of the five-day follow up report, dated as having been completed by the DON on 07/30/11, revealed the corrective action taken by the facility was suspension and termination of the CNA. - Review of the CNA's time card revealed she worked a complete shift on 07/24/11, arriving at 2:55 p.m. and leaving at 10:58 p.m. This employee also worked a double shift from 2:54 p.m. on 07/28/11 until 7:00 a.m. on 07/29/11. - Review of the ""Current Employee List As of 8/1/11"", which was supplied to the survey team at the start of this on-site complaint investigation on 08/01/11, revealed Employee #174 was identified as a current employee. - The DON, when interviewed at 2:00 p.m. on 08/02/11, was unable to provide evidence the CNA was suspended when the facility became aware of the incident. She also verified the CNA continued to work at the facility until 07/28/11. The DON further verified the incident was not immediately reported to State officials on 07/24/11. The DON stated she faxed the information to State officials on 08/01/11. - The administrator, when interviewed at approximately 10:00 a.m. on 08/04/11, stated, ""There was a communication problem between the HR (human resources) and the scheduler. It happened, that is all I can say. It should not have happened."" - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress."" -- d) Resident #64 Review of an immediate fax reporting form sent to the Nursing Home Program revealed incidents involving Resident #64, which were noted by the person completing the form (the DON) as having occurred on 05/25/11. The description of the incident was as follows (quoted as written): ""Resident report to one nurse that he was beaten-up in the shower room and to another nurse he relayed he was smacked in the face & punched in the ribs while in his room. Report made to nursing staff evening of 5/26/11."" Where the form prompted the author to identify the name of the alleged perpetrator, the person completing the form (the DON) noted ""Unknown"". The DON dated her signature to indicate she completed this immediate reporting form on 05/27/11. This immediate reporting was not completed within twenty-four (24) hours of the facility's receipt of the complaint by Resident #64. - Review of the facility's internal investigation into this incident revealed the following statements had been collected: - A typed statement from an LPN (Employee #177), signed by Employee #177 on 05/26/11, which stated (quoted as typed): ""Upon assessment and administration of meds resident told this nurse that Wed night the 18th day of May 2011 That the two aids that were giving (Resident #64) his shower were pulling and tugging on him so hard that he heard his ribs crack and he thought they were broke. Resident also stated that 'Dave told him that he was going to kill me."""" - A typed statement from an RN (Employee #35), signed by Employee #35 on 05/26/11, which stated (quoted as typed): ""RESIDENT STATES, 'DANNY AND JIMMY WAS YANKING AND PULLING ON ME LAST WEDNESDAY CRACKING MY RIBS'. ..."" - The facility's internal investigation contained no other statements, including no statements from any nursing assistants assigned to care for the resident on 05/18/11 and no statement from the resident's roommate. - Review of the five-day follow-up report for Resident #64 revealed the following (quoted as written): ""Resident initial stated he was beaten-up in the shower, then stated he was pulled & tugged on in the shower, then stated he was slapped & hit when in bed. first talked about 'Dave' then 'Danny & Jimmy' (1) No marks on pt (patient) (2) Rib x-ray negative (3) No employees caring for resident by the names of 'Dave, Danny, or Jimmy.' Claim unsubstantiated."" The form was signed by the person completing the report (the DON) on 05/31/11. - During an interview with the DON on the afternoon of 08/02/11, she stated the facility did not have any employees with the same first name as identified by Resident #64 (""Dave"", ""Danny"", or ""Jimmy""); therefore, no statements were taken from any other employees. - Review of the nursing schedule revealed two (2) nursing assistants (Employees #176 and #82) whose first names matched two (2) of the three (3) nicknames identified by Resident #64. Both nursing assistants were employed at the facility during the time the alleged abuse was reported by the resident, and Employee #176 worked a double shift on Resident #64's floor on the date of the alleged abuse (05/18/11). - When interviewed on 08/03/11 at 1:33 p.m., a nursing assistant (Employee #120) stated Resident #64 frequently made complaints about people beating him up and not receiving care. She further added that Resident #64 had not complained about people beating him up since he accused Employee #176 of beating him up. When interviewed on 08/03/11 at 1:55 p.m., a licensed practical nurse (LPN - Employee #62) stated Resident #64 was always complaining about his care. The LPN reported Resident #64 would always say that Employee #176 was hitting him. She stated that, if the facility reported everything the resident said, they would be reporting every day. - There was no evidence to reflect the facility conducted a thorough investigation into this resident's allegation of physical abuse by two (2) employees whom the resident identified by first name and who were employed at the time of the alleged incident. .",2015-02-01
10522,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-10-19,225,D,1,0,N32O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's resident concern forms, medical record review, facility policy, and staff interview, the facility failed to immediately report (within twenty-four (24) hours) and/or thoroughly investigate an allegation of neglect to all applicable State officials as required by law. This was true for one (1) of four (4) resident concern forms reviewed for the past two (2) months. Resident identifier: #92. Facility census: 120. Findings include: a) Resident #92 Review of the resident concern forms revealed the facility received a concern from Resident #92 on 09/13/11. The resident reported the concern to Employee #136, a certified occupational therapy assistant (COTA), who documented the following under the heading ""Documentation of Resident Concern"": ""Resident reports not being ready for her appointment when the ambulance arrived. She reports being wet and having to leave in the clothes she slept in which were dirty."" Further review of the concern form revealed the facility met with the resident's niece. Under the heading ""Documentation of Facility Follow-Up"", the individual assigned to take action on this concern was the director of nursing (DON), who documented having a meeting with the resident's niece (with no date of time of this meeting noted). According to the documentation on the concern form, the concern was resolved, and on 09/26/11, the DON recorded the following under the heading ""Resolution of Resident Concern"": ""Resident was clean & dry when she went to doctor's appointment. Niece requested that resident be given shower prior to any appointments."" There was no additional information attached to this concern form, such as documentation of an interview with the resident or witness statements from the COTA, the ambulance crew, the nursing assistant assigned to the resident, or any other staff member who may have observed the resident before she left for her appointment on 09/13/11. -- Review of Resident #92's nursing notes revealed the resident went out of the facility at 9:00 a.m. on 09/13/11 for a doctor's appointment and returned to the facility from the appointment at 10:05 a.m. Review of the social services notes revealed the social worker told the resident, on 09/12/11, that she had a doctor's appointment scheduled on 09/13/11. -- Employee #136, when interviewed on 10/18/11 at approximately 10:35 a.m., verified she had completed the concern form for the resident, because she (the employee) was present when the situation occurred. Employee #136 stated she had put the resident's shoes on and combed her hair while the ambulance attendants waited. She said she did not summon additional staff to assist in dressing the resident, because the ambulance attendants stated they needed to leave or they would be late for the appointment. Employee #136 did verify the resident had food on her shirt. This employee did not know if the resident was wet, and she did not know if the resident was still wearing the same clothing she had on the night before. -- Resident #92, when interviewed on 10/18/11 at approximately 3:20 p.m., was asked if she had expressed a concern related to not being dressed for her doctor's appointment. The resident remembered the incident, stated she had an appointment with her cardiologist, and said, ""No one got me ready to go."" She said she told her nursing assistant about the doctor's appointment when the nursing assistant delivered her breakfast tray that morning. ""I told the girl I had a doctor's appointment and needed to get ready."" She reported the nursing assistant told her, ""Go ahead and eat your food, because you have plenty of time."" (The resident did not know the name of her nursing assistant. ""It was one of those new girls."") Resident #92 stated she told the nursing assistant she would rather get ready for the appointment than eat breakfast. The nursing assistant replied, ""I will come back in plenty of time to get you ready."" The resident stated she finished eating her breakfast, and when the ""girl from therapy"" and the ambulance driver entered her room at the same time, she was not ready for her appointment. She stated the ambulance driver and the ""girl from therapy"" helped put her shoes on, and she left the building for her appointment. The resident stated she was still dressed in the clothes she had slept in, she had food on her shirt from breakfast, and she was ""wet"". (By ""wet"", she explained the incontinence brief she was wearing was wet with urine.) The resident further explained she has [MEDICAL CONDITION] and has tremors, which cause her to sometimes spill her food; she said food from breakfast was still on her shirt. She stated, ""I did not want to go to the doctor's office like that. Would you?"" She said she would complain again if this happens. -- Review of the medical record revealed this [AGE] year old female was admitted to the facility on [DATE], and her active [DIAGNOSES REDACTED]. On 08/05/11, her physician determined she had the capacity to understand and make her own informed medical decisions. Review of her minimum data set (MDS), with an assessment reference date of 09/23/11, revealed the assessor completed a brief interview for mental status (BIMS) which yielded a score of ""15"" out of ""15"", denoting the resident was cognitively intact. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) User Manual for MDS 3.0 states the BIMS is ""intended to determine the resident's attention, orientation, and ability to register and recall new information."" -- The DON, when interviewed on the morning of 10/18/11, verified she had not reported the incident with Resident #92 to State officials, because she did not feel it was neglect. The DON stated she investigated the incident by speaking to the unit nurse. According to the DON, the nurse saw the resident before she left the facility and the resident was clean. The DON also verbally confirmed she had a meeting with the resident's niece after the concern form was received. No further information, written or verbal, was presented by the DON regarding a thorough investigation into the allegations made by the resident as recorded on the concern form. -- The facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" was reviewed. According to the facility's policy (on page 11): ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)."" -- Review of Section 9-6-11 of the West Virginia State Code found: ""A report of neglect or abuse of an incapacitated adult or facility resident or of an emergency situation involving an adult shall be made immediately by telephone to the department's local adult protective services agency and shall be followed by a written report by the complainant or the receiving agency within forty-eight hours ..."" -- According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities (Revision, August 2009), 42 CFR 488.301 defines neglect as ""failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (NOTE: This is regardless of whether the perpetrator actually meant or intended to cause harm.)"" Allegations of neglect are to be reported to the State survey agency, adult protective services, and the ombudsman program. -- Resident #92 verbalized an allegation of neglect when she reported she went to a doctor's appointment with a wet incontinence brief, clothing she had slept in the previous night, and food on her shirt. The resident voiced she did not want to be sent to her appointment in this condition and stated she would complain it this situation ever occurred again. -- This is a REPEAT deficiency. Review of this facility's survey history revealed this facility was cited at F225 for failing to immediately report and/or thoroughly investigate allegations of abuse and neglect on seven (7) separate occasions over the past five (5) years as the result of survey events that concluded on 08/04/11, 03/17/11, 12/22/10, 04/29/09, 11/13/08, 1115/07, and 12/14/06. (This excludes those occasions when F225 was cited for the facility's failure to comply with other aspects of this regulation, such as conducting pre-employment screening.) .",2015-02-01
10523,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-10-19,226,D,1,0,N32O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of resident concern forms, staff interview, medical record review, resident interview, and review of facility policy, the facility failed to implement its policy and procedures for reporting and investigating an allegation of neglect as follows: The facility failed to immediately report (within no more than twenty-four (24) hours) and thoroughly investigate all allegations of neglect to applicable State officials as required by law. This deficient practice was true for one (1) of four (4) resident concern forms reviewed for the past two (2) months. Resident identifier: #92. Facility census: 120. Findings include: a) Resident #92 Review of the resident concern forms revealed the facility received a concern from Resident #92 on 09/13/11. The resident reported the concern to Employee #136, a certified occupational therapy assistant (COTA), who documented the following under the heading ""Documentation of Resident Concern"": ""Resident reports not being ready for her appointment when the ambulance arrived. She reports being wet and having to leave in the clothes she slept in which were dirty."" Further review of the concern form revealed the facility met with the resident's niece. Under the heading ""Documentation of Facility Follow-Up"", the individual assigned to take action on this concern was the director of nursing (DON), who documented having a meeting with the resident's niece (with no date of time of this meeting noted). According to the documentation on the concern form, the concern was resolved, and on 09/26/11, the DON recorded the following under the heading ""Resolution of Resident Concern"": ""Resident was clean & dry when she went to doctor's appointment. Niece requested that resident be given shower prior to any appointments."" There was no additional information attached to this concern form, such as documentation of an interview with the resident or witness statements from the COTA, the ambulance crew, the nursing assistant assigned to the resident, or any other staff member who may have observed the resident before she left for her appointment on 09/13/11. -- Review of Resident #92's nursing notes revealed the resident went out of the facility at 9:00 a.m. on 09/13/11 for a doctor's appointment and returned to the facility from the appointment at 10:05 a.m. Review of the social services notes revealed the social worker told the resident, on 09/12/11, that she had a doctor's appointment scheduled on 09/13/11. -- Employee #136, when interviewed on 10/18/11 at approximately 10:35 a.m., verified she had completed the concern form for the resident, because she (the employee) was present when the situation occurred. Employee #136 stated she had put the resident's shoes on and combed her hair while the ambulance attendants waited. She said she did not summon additional staff to assist in dressing the resident, because the ambulance attendants stated they needed to leave or they would be late for the appointment. Employee #136 did verify the resident had food on her shirt. This employee did not know if the resident was wet, and she did not know if the resident was still wearing the same clothing she had on the night before. -- Resident #92, when interviewed on 10/18/11 at approximately 3:20 p.m., was asked if she had expressed a concern related to not being dressed for her doctor's appointment. The resident remembered the incident, stated she had an appointment with her cardiologist, and said, ""No one got me ready to go."" She said she told her nursing assistant about the doctor's appointment when the nursing assistant delivered her breakfast tray that morning. ""I told the girl I had a doctor's appointment and needed to get ready."" She reported the nursing assistant told her, ""Go ahead and eat your food, because you have plenty of time."" (The resident did not know the name of her nursing assistant. ""It was one of those new girls."") Resident #92 stated she told the nursing assistant she would rather get ready for the appointment than eat breakfast. The nursing assistant replied, ""I will come back in plenty of time to get you ready."" The resident stated she finished eating her breakfast, and when the ""girl from therapy"" and the ambulance driver entered her room at the same time, she was not ready for her appointment. She stated the ambulance driver and the ""girl from therapy"" helped put her shoes on, and she left the building for her appointment. The resident stated she was still dressed in the clothes she had slept in, she had food on her shirt from breakfast, and she was ""wet"". (By ""wet"", she explained the incontinence brief she was wearing was wet with urine.) The resident further explained she has [MEDICAL CONDITION] and has tremors, which cause her to sometimes spill her food; she said food from breakfast was still on her shirt. She stated, ""I did not want to go to the doctor's office like that. Would you?"" She said she would complain again if this happens. -- Review of the medical record revealed this [AGE] year old female was admitted to the facility on [DATE], and her active [DIAGNOSES REDACTED]. On 08/05/11, her physician determined she had the capacity to understand and make her own informed medical decisions. Review of her minimum data set (MDS), with an assessment reference date of 09/23/11, revealed the assessor completed a brief interview for mental status (BIMS) which yielded a score of ""15"" out of ""15"", denoting the resident was cognitively intact. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) User Manual for MDS 3.0 states the BIMS is ""intended to determine the resident's attention, orientation, and ability to register and recall new information."" -- The DON, when interviewed on the morning of 10/18/11, verified she had not reported the incident with Resident #92 to State officials, because she did not feel it was neglect. The DON stated she investigated the incident by speaking to the unit nurse. According to the DON, the nurse saw the resident before she left the facility and the resident was clean. The DON also verbally confirmed she had a meeting with the resident's niece after the concern form was received. No further information, written or verbal, was presented by the DON regarding a thorough investigation into the allegations made by the resident as recorded on the concern form. -- Resident #92 verbalized an allegation of neglect when she reported she went to a doctor's appointment with a wet incontinence brief, clothing she had slept in the previous night, and food on her shirt. The resident voiced she did not want to be sent to her appointment in this condition and stated she would complain it this situation ever occurred again. -- Review of Section 9-6-11 of the West Virginia State Code found: ""A report of neglect or abuse of an incapacitated adult or facility resident or of an emergency situation involving an adult shall be made immediately by telephone to the department's local adult protective services agency and shall be followed by a written report by the complainant or the receiving agency within forty-eight hours ..."" -- According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities (Revision, August 2009), 42 CFR 488.301 defines neglect as ""failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (NOTE: This is regardless of whether the perpetrator actually meant or intended to cause harm.)"" Allegations of neglect are to be reported to the State survey agency, adult protective services, and the ombudsman program. -- The facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" was reviewed. According to the facility's policy (on page 11): ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency).""",2015-02-01
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
10526,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2011-10-20,252,E,1,0,ZWNE11,". Based on observation and staff interview, the facility failed to provide a clean and sanitary environment for residents, by failing to store wash basins and bedpans appropriately and failing to provide a beauty salon for residents that is clean and sanitary and provides an enjoyable experience for residents to have their hair done. During the initial tour of the facility it was observed a resident's wash basin was stored on the floor under the hand sink in room A-4 and in room B-12 a bedpan was stored on the floor beside the toilet in the bathroom and a wash basin was on the floor under the hand sink. This practice has the potential to affect all residents who use a wash basin or bedpan and all residents who use the facility beauty shop. Facility census: 59. Findings include: a) During the initial tour of the facility on 10/19/11 beginning at 8:45 a.m., observation of Room A-4 found a wash basin sitting on the floor under the hand sink and observation of Room B-12 found a wash basin sitting on the floor under the hand sink and a bed pan sitting on the floor beside the toilet in the bathroom. During further tour of the facility on 10/19/11 at 3:45 p.m., accompanied by the assistant director of nursing (ADON - Employee #42), these same observations were again made in Rooms A-4 and B-12. In an interview during the tour, the ADON agreed the wash basins and the bed pan were not stored appropriately and that this was a sanitation issue. -- b) During observations of the facility's beauty shop on 10/19/11 and 10/20/11, the following cleanliness / sanitation issues were found: - The tops of the counters were dirty with cut hair and dust. - The hair drier was dirty with cut hair and dust. - The hair washing sink and the hand sink were dirty. There was a spider web behind the faucet of the hand wash sink. - Two (2) pair of hair clippers were dirty with cut hair, and the stand of the one (1) clippers was stored in was dirty with cut hair. The cutting surfaces of the clippers were in need of cleaning and sanitizing. - The barber chair had rusty arms and was dirty with debris and cut hair. - The dust pan (which had been used to sweep up hair) was full of cut hair and stored in a corner of the room. The appearance of the beauty shop was not a pleasing, inviting environment for residents to enjoy while having their hair done. During an interview with the director of nursing and the ADON in the beauty shop on 10/19/11 at 4:00 p.m., the condition of the beauty shop was discussed, and they agreed the condition of the shop was a concern.",2015-02-01
10527,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,463,D,0,1,4DOJ11,"Based on performance testing and staff interview, the facility failed to ensure the nurse call system was fully functional for all residents. The call bells for room #108 did not function when tested by the surveyor. This was evident for one (1) of fourteen (14) sampled residents whose call bells were evaluated for functioning. Facility census: 112. Findings include: a) The surveyor evaluated the operation of nurse call bells on the afternoon of 10/06/09 for the residents in the Phase I sample. This performance testing discovered the call bells did not activate for the resident in room #108. The surveyor requested the nursing assistant (Employee #62) who was in the hall way to check the call light with her. The light was found to not operate for the resident in either bed in the room. .",2015-02-01
10528,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,252,E,0,1,4DOJ11,"Based on staff interview and observation, the facility failed to provide a safe, clean, comfortable environment for its residents. The walls around the nursing station on the West wing were banged and scratched; bangs and scratches were noted n the wall of the shower room near the tub, and the wall in the hallway outside of the shower room was missing wallpaper. These conditions did not prevented the surfaces from being easily cleaned. This was evident for one (1) of two (2) nursing units. Facility census: 112. Findings include: a) Observations, on the afternoon of 10/06/09, found the walls around the nursing station serving the West wing of the facility were banged and scratched. The wall of the shower room serving this unit was banged and scratched above the baseboard. Additionally, a section of wall paper was missing below the hand railing in the outside hall way of the 300 wing. These conditions do not allow the areas to be easily cleaned by staff. The maintenance supervisor verified these observations later in the afternoon of 10/06/09. .",2015-02-01
10529,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,364,D,0,1,4DOJ11,"Based on random observation on 10/05/09 and staff interview, the facility failed to ensure meals were pleasing in appearance. This was evident for one (1) resident of random opportunity. Resident identifier: #104. Facility census: 112. Findings include: a) Resident #104 The evening meal was observed on the West wing on 10/05/09, in the unit's small dining room. Resident #104 was noted to receive a stuffed pepper which had juice that was running all over the plate. A side dish of greens was found to be setting in the juice. This did not make for an appealing appearance on the tray. This observation was discussed with the dietary manager at 11:10 a.m. on 10/08/09. .",2015-02-01
10530,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,502,D,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory tests as ordered by the physician. These laboratory tests were ordered to be done every month and, as of 10/06/09, they had not been done since 08/21/09. Ordered test were not completed for one (1) of twenty (20) sampled residents. Resident identifier: #51. Facility census: 112 Findings include: a) Resident #51 Review of the medical record revealed this resident had a physician's orders [REDACTED]. Further review of the medical record revealed this resident's last CBC and BMP had been done on 08/21/09. There was no evidence to indicate these tests were performed in September 2009. The registered nurse (Employee #16), when questioned about the laboratory data on 10/06/2009 at 2:00 p.m., was unable to locate the data and verified that, after researching this, the resident had not had the laboratory tests completed as ordered. The facility performed these test immediately after it was identified that they were not completed.",2015-02-01
10531,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,318,D,0,1,4DOJ11,"Based on medical record review, observation, and staff interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (1) of twenty (20) sampled residents. Resident #12 was unable to fully extend her legs and had limited range of motion. Review of assessments, nursing notes, and care plan failed to find evidence the resident was assessed, care planned, or provided services to prevent further decrease in range of motion. Facility census: 112. Findings include: a) Resident #12 Observation of this resident on 10/05/09, 10/07/09, and 10/08/09, found the resident's legs would not fully extend. The resident was observed on 10/06/09 while a nursing assistant (NA - Employee #61) attempted to reposition the resident in the bed. The resident was observed while seated in a geri-chair on 10/06/09 and 10/07/09, and the resident's legs did not fully extend on any of the observations. During observations on the mid-afternoon of 10/07/09, with the director of nursing (DON) and an occupational therapist, two (2) NAs (Employees #56 and #68) sat the resident on the side of the bed, and the occupational therapist handed the NAs a gait belt. The resident's bed was low and unable to be raised in order for the NAs to help the resident sit in an upright position. The resident was stooped over with her head leaning forward towards her knees. When questioned if the gait belt was always used to transfer the resident, Employee #56 said, ""Always, sometimes."" The resident was able to put her feet down but was not able to fully extend her legs in order to stand up, and she was not able to fully bear any weight. The DON had to assist the NAs by bringing the geri chair behind the resident and holding it in place while they lifted the resident into the geri-chair. With the occupational therapist present, Resident #12 then pulled her legs up towards her chest and assumed a drawn up position, allowing her feet to again come to rest on the metal bar located between the chair and the elevated foot rest. The occupational therapist indicated she was there to observe the resident for possible screening. A review of the physician's progress notes, nursing assessments, nursing notes, and therapy notes, from the resident's admission 08/01/08 through 10/08/09, failed to find evidence the resident had been evaluated for decreased range of motion or contractures. There was no care plan to address her range of motion, nor was there evidence she had received services to prevent any further decrease in range of motion. On 10/08/09 at 9:00 a.m., the resident was observed seated in a geri chair in the therapy room, and the physical therapist attempted to evaluate the resident. The resident did not cooperate, and the evaluation was unable to be completed. .",2015-02-01